Climate Change
 - Question

Baroness Ritchie of Downpatrick: To ask Her Majesty’s Government what progress they have made adapting the United Kingdom to climate change risks since the Climate Change Committee’s Independent Assessment of UK Climate Risk, published in June 2021.

Lord Benyon: My Lords, the Government welcome the Climate Change Committee’s constructive assessment, which informed the UK Climate Change Risk Assessment 2022, published in January. Since then, we have started to develop the third national adaptation programme, using this risk assessment. We know that we must go further and faster to prepare for the impacts of a warmer world. Adapting to climate change is a government-wide challenge, and we are looking across all government policies and programmes to develop NAP 3.

Baroness Ritchie of Downpatrick: My Lords, the Climate Change Committee clearly recommended that the Government publish how we would adapt to 2 degrees of warming and assess the risks for 4 degrees in the next national adaptation programme, due in 2023. However, the response to the CCC recommendation said only that the Government would address the risks and opportunities of a scenario of 2 degrees of warming. In such circumstances, is it the Government’s view that it is not worth assessing the risks of 4 degrees of warming for the UK, or was this omission accidental? Is there any assessment yet of yesterday’s alarming report, which stated that all of us would cause irreparable damage to our ecosystem?

Lord Benyon: The noble Baroness is entirely right in her assessment. The Dasgupta review and other work has indicated the impact that global warming will have on our ecosystems and economy. The CCC has identified eight priority areas for urgent attention and considered 61 UK-wide climate risks and opportunities cutting across multiple sectors. We are looking at every risk and tackling those eight priorities, four of which come directly under Defra and all of which are cross-government.

Lord Forsyth of Drumlean: My Lords, does my noble friend not recognise that, since the climate change conference, one of the risks that we need to be concerned about is security of supply for the energy  that we need to keep people warm and keep our economy operating? Does he not think that this might be the moment when we should refresh our ideas on whether we allow fracking and the exploration of gas in our own resources so that we can maintain that security of supply?

Lord Benyon: The greatest stability in an unstable world is for us to decarbonise our economy as much as we can and become less reliant on other countries, or indeed on hydrocarbons, for our future. The Government’s strategy thus far has been absolutely right, and we will continue to make sure that our economy is resilient to the kind of global instability that we are experiencing at the moment.

Lord Krebs: My Lords, one of the risks highlighted by the Climate Change Committee is the risk to buildings of overheating from extreme heat waves. In the light of that, can the Minister tell us what proportion of the 460,000 new homes built in the last two years are designed to be resilient and cope with extreme heat waves, which are likely to be the norm by 2050?

Lord Benyon: The noble Lord is very experienced in this whole area of adaptation. The Department for Levelling Up, Housing and Communities has introduced a new requirement on overheating into the building regulations to ensure that new residential buildings are built for a warming climate. The new requirement prioritises addressing overheating through passive measures, including reducing solar gains and sufficient removal of heat.

Lord Oates: My Lords, the Minister will be aware of the warning in yesterday’s report that increasing severe impacts to humans, nature and the climate can be expected as global temperatures rise by 1.5 degrees centigrade. Will he agree to meet me and other supporters of the climate and ecology emergency Bill to discuss how the UK can use its COP 26 presidency to lead by example and deliver a joined-up strategy to restore nature and limit warming to 1.5 degrees?

Lord Benyon: My colleagues at Defra—my noble friend Lord Goldsmith, who led on this at COP, and my colleague Jo Churchill, who leads on climate change adaptation—and I would certainly be happy to meet the noble Lord to explain how we hope we are still on track for 1.5 degrees, while ensuring that we adapt to all the risks in the report we are responding to that we could face in the coming decades.

Lord Rooker: Does the Minister accept that one of the problems with renewables is intermittency of supply? Surely one way round that serious problem for the next decade would be to use gas like we do now but capture the carbon. The Government have never taken carbon capture and storage seriously and are now putting all their eggs in the hydrogen basket. Carbon capture and storage will enable us to deal with the intermittency, I accept by burning a fossil fuel, but  allow no carbon to go into the atmosphere. Why are the Government so reluctant to push carbon capture and storage?

Lord Benyon: The Government have co-financed a number of research projects on this. It remains a technology that has potential. We are working to understand it, its viability and all its implications to ensure that our infrastructure in the North Sea can be used as we develop it.

Baroness McIntosh of Pickering: My Lords, does my noble friend agree that planting trees can contribute to mitigating and adapting to climate change, particularly to reduce the threat of flooding? Will he give an assurance that the trees that will be planted under the Government’s programme and ELMS will be fit for purpose and will not contribute to the possibility of flooding?

Lord Benyon: New tree planting is absolutely fundamental to our new ELMS and environmental policies. We have very bold targets for tree planting. However, my noble friend is absolutely right: they need to be in the right place. There is incredibly powerful evidence to show that a tree’s ability to move water underground from the surface can enormously contribute to flood mitigation. It is very much part of our policy.

Baroness Jones of Whitchurch: My Lords, over the last fortnight vast swathes of the UK were battered by three ferocious storms in seven days, leading to the heartbreak of many thousands of properties being flooded, some of them for a second or third time. We are told by the Met Office that these extreme weather events will continue and get worse. The Government recognise that flooding is a key risk in their response to the CCC report, but what urgent action is being taken to follow that up and to accelerate building the defences that we will need not only now but for the future to withstand those threats? Can he give an assurance that this action is being accelerated?

Lord Benyon: I can absolutely do that. We have doubled our investment in flood defences to a record £5.2 billion. with some 2,000 new defence schemes over the next six years. This programme will better protect 336,000 properties, including homes and non-residential properties such as schools, hospitals and transport links. But, as I just said to my noble friend Lady McIntosh, concrete and steel are not the sum total of this; it is also about planting trees and using nature to slow water. That is at the fundamental heart of our new agricultural policy.

Baroness Bennett of Manor Castle: My Lords, this morning Reuters published draft proposals from the European Commission that will be published next week including proposals for national Governments to tax the windfall profits that energy companies have made from high gas prices. If the Government want to be world-leading, do they not need to get in in the next  few days to bring in a windfall tax on those gas prices that could then be used for adaptation measures, identified as urgently needed in this report?

Lord Benyon: I will relay the noble Baroness’s suggestion to the Chancellor and he will consider it within the Government’s fiscal policies.

Lord Geddes: My Lords, it is rare that I disagree, or have the trepidation to disagree, with the noble Lord, Lord Rooker, but does my noble friend agree that tidal power is utterly predictable?

Lord Benyon: I entirely agree with my noble friend that it is predictable. It is another emerging technology and one that we are investing in with academia to try to see its development around our coast.

Baroness Hayman: My Lords, the IPCC report yesterday made clear the overwhelming risks of humanitarian crises, food insecurity, flooding and other problems for some of the most exposed places in the world. What progress have we made in our ongoing presidency of COP in terms of global action on mitigation?

Lord Benyon: The noble Baroness is absolutely right. Climate change hurts the most vulnerable most. I have been in parts of world where I have seen the impact of climate change. I have seen the look on people’s faces as they have to move from one island to another because they can no longer survive on the island of their birth. We are determined to use our experience and our presidency of COP with our successors to make sure that we reflect the needs of the most vulnerable on this planet.

Lobbying of Ministers
 - Question

Lord Bird: Moved by Lord Bird
To ask Her Majesty’s Government what steps they will take to ensure there is transparency about the lobbying of ministers.

Lord True: My Lords, the statutory register of consultant lobbyists ensures the transparency of those seeking to lobby Ministers and Permanent Secretaries on behalf of a third party. The register complements departments’ long-standing policy of publishing details of Ministers’ meetings with external organisations on GOV.UK on a quarterly basis.

Lord Bird: That is a very good Answer, my Lords. The only problem is that we have evidence over the past few months of ex-Prime Ministers, ex-Ministers and MPs trying to influence in a way that undermines democracy. If you really want to destroy democracy, destroy belief in the Government and their ability to  hold their head up and not participate in the pork barrel. If you want to get on in this world, there is an old saw: “Get yourself a government contract”. The past few months have been abysmal.

Lord True: My Lords, the noble Lord, whom I respect greatly and who has been in my office a number of times advocating for causes in which he believes, makes some exaggerated charges. It is extremely dangerous to peddle around the view that there is endemic corruption in politics in this country, whoever is in office.

Baroness Hayter of Kentish Town: My Lords, one of the problems is that, as the Minister said, the register is of consultant lobbyists only. It does not include in-house lobbyists; all the big firms have in-house lobbyists. Is it not time that we made that register a register of all lobbyists, not just consultants?

Lord True: My Lords, when the register was introduced by a Conservative Government, other propositions were put forward. At the time we felt that widening the scope could place a significant burden on charities and so on. However, we are conducting post-legislative scrutiny of the lobbying legislation. That has obviously been affected by the progress of Covid, but the point the noble Baroness and others make will be taken into consideration.

Lord Stunell: My Lords, in June last year the Committee on Standards in Public Life, of which I am a member, submitted recommendations to the Prime Minister for action by the Cabinet Office on ministerial lobbying. After eight months of careful consideration, can the Minister for the Cabinet Office tell us how many of the seven recommendations in that report he intends to implement, and on what timescale?

Lord True: My Lords, a number of important documents and proposals have been presented to the Government; the noble Lord mentions one of them. We have the Boardman recommendations and the post-legislative scrutiny, which I have just mentioned. All those mesh together and the Government will respond, as I said in the previous answer.

Lord Lansley: My Lords, I was responsible in the other place for the passage of the Bill on transparency of lobbying, et cetera, because Nick Clegg, then the Deputy Prime Minister, did not want to be responsible for it, although it was a coalition Bill. Does my noble friend recall that the record of ministerial meetings published quarterly is not confined to consultant lobbyists and includes meetings that Ministers have with external organisations? That is the central mechanism by which the transparency is achieved in reality. Does my noble friend agree that, as long as Ministers are honest and open about their meetings, we can see who they are being lobbied by?

Lord True: My noble friend makes a very fair point and I pay tribute to him for taking up the work that he tells us Mr Clegg did not wish to take up. The  transparency of publishing the details of Ministers’ meetings on a quarterly basis is important, and this is among the issues the Government are considering.

Lord Morris of Aberavon: My Lords, since the most toothless body I have ever served on was the business appointments committee—too feeble to halt the revolving doors for both Ministers and Crown servants—will the Government bring forward proposals now to radically and totally reform the system?

Lord True: My Lords, we are in regular contact with my noble friend Lord Pickles, who chairs ACOBA. Its work is important. As I have said to your Lordships, we think that putting it on a statutory basis would be out of line with the general principle that Ministers and officials are subject to the same legal system as others. We are open to change and constant reflection, and I have had meetings with my noble friend Lord Pickles on that subject.

Viscount Waverley: My Lords, how would the Minister recommend that the provision of cutting-edge information that would enable Ministers to make appropriate decisions be conducted, so that the information is at their behest to enable that very same process of decision-making?

Lord True: I apologise but I did not absolutely get the point that the noble Viscount makes. It is certainly the case that in a free society and a free country, it is perfectly reasonable for individuals or organisations to go to their MP, the Government or the local council to put the case for changes and provide information from outside, which may help government, councils or others make decisions. That is an inherent part of a free society.

Lord Clark of Windermere: My Lords, over the years the process of providing information to civil servants, Ministers and parliamentarians has traditionally been done by lobbying, which is part of the democratic process. There is a belief that, of late, lobbying has become an integral part of the process of winning government contracts. Will the Minister reflect on that and discuss the suggestion with some of his colleagues?

Lord True: My Lords, obviously I agree with what the noble Lord said in the first part of his question: in a free society it is an inherent right to make representations. As I have told the House, the Government are open to considering any proposals that do not restrict that. Lobbying and approaches to government should be transparent and properly conducted and exclude personal advantage; that is the purpose of the system.

Baroness Smith of Basildon: My Lords, I come back to the point made by the noble Lords, Lord Clark and Lord Stunell. The Minister will have seen the Upholding Standards in Public Life report, which says that, in a liberal democracy, lobbying is an integral  and sensible part of making views known to government but that trust in the integrity of our democracy is undermined when it is
“associated with money, undue influence and secrecy.”
That is the real problem here. He did not respond to the noble Lord, Lord Stunell, but I ask him to comment on two specific recommendations of the report. One, very appropriately, is that the Government should give up-to-date guidance to make it clear that informal lobbying and lobbying via WhatsApp or Zoom should also be reported to officials. The other is that that should include not just Ministers and civil servants but special advisers. Will the Government take those recommendations on board?

Lord True: My Lords, we are certainly aware of those points and, obviously, the investigation by Mr Boardman looked into issues relating to the first point that she made. I assure the House that all the various reports and recommendations put forward are being considered. I hope to come back to your Lordships before too long with further material proposals.

Baroness Jones of Moulsecoomb: My Lords, it is good to know who has given what to whom, but how do we monitor what the person who has been given money is doing for the money? For example, it is reported that the Prime Minister has taken £2.3 million from Russian sources since he was elected Prime Minister. What has he done for that?

Lord True: My Lords, the noble Baroness makes an allegation under privilege; perhaps she would like to repeat that outside the House.

Lord Forsyth of Drumlean: My Lords, will my noble friend take this opportunity to pay tribute to the trade union movement and the fantastic job that it has done in lobbying Labour and Conservative Governments?

Lord True: I would indeed; I am quite old fashioned and I greatly respect the trade union tradition. I also respect the freedom of politicians such as Mr Ed Davey, who became a lobbyist immediately after losing his ministerial job in 2015.

Lord Wallace of Saltaire: My Lords, the Sunday Times two weeks ago told us a lot about the donors board, which has unpublished, unremarked, unrecorded meetings with the Prime Minister and other senior Members, some of whom clearly have actively lobbied for their own interests, while some have received public contracts. If we are committed to transparency, can we not be assured that such meetings will be properly recorded and details of those who attend published afterwards?

Lord True: My Lords, once again, I take note of what the noble Lord says. In the system that we have in this country, ministerial meetings are noted by officials; as we established earlier in this exchange and as my noble friend Lord Lansley said, data is regularly published thanks to his legislation.

Eating Disorders
 - Question

Baroness Parminter: To ask Her Majesty’s Government, further to the report of the Parliamentary and Health Service Ombudsman Ignoring the alarms: How NHS eating disorder services are failing patients, published on 6 December 2017, what steps they are taking to ensure that eating disorders are taught appropriately in medical schools.

Lord Kamall: My Lords, following the Parliamentary and Health Service Ombudsman’s report regarding the tragic death of Averil Hart, the Department of Health and Social Care has been engaging with partners through a delivery group led by NHS England and NHS Improvement to continue to address the recommendations. This includes work with Health Education England to improve training for GPs and with the General Medical Council to ensure that eating disorders are included among outcome measures for newly qualified clinicians.

Baroness Parminter: I thank the Minister for his reply. GPs receive on average less than two hours’ training for eating disorders. Inadequate training was identified by the PHSO report in 2017, as he says, and by numerous coroners’ reports since then, including the latest Prevention of Future Deaths report in Manchester in December following the tragic death of Nichola Lomax. What specifically is the Minister doing to hold the GMC, the Academy of Medical Royal Colleges, Health Education England, NHS England and NHS Improvement to account for their responsibility to ensure that trainee doctors graduate with the skills and the knowledge to be able to identify, safely manage and refer patients with eating disorders?

Lord Kamall: The noble Baroness raises a very important point about how we identify the issues and tackle them. It is two-pronged: one way is about the amount of investment into mental health services, including tackling disorders, and the other is training. NHS England and NHS Improvement have been working with Health Education England and other partners to look at training courses that will increase the capacity of the existing workforce to provide evidence-based treatment to more people. We are also working with the GMC and the Academy of Medical Royal Colleges as well as Beat representatives. In addition, Health Education England is looking to increase the exposure of doctors to eating disorders. The GMC’s Outcomes for Graduates states that
“Newly qualified doctors must explain and illustrate”
their understanding of
“the principles for the identification, safe management and referral of patients with mental health conditions”,
including eating disorders.

Baroness Wheatcroft: My Lords, the eating disorders charity Beat conducted a survey last autumn and found that 69% of those with eating disorders had found that their GPs did not know what to do with them. That result was, if anything, worse than the same survey conducted five years earlier. It is good the Government are acknowledging that medical students need to learn more about how to deal with eating disorders, but could the Minister give us a guarantee that those GPs already in practice who know nothing about eating disorders at the moment—and choose not to—can be helped to understand the issue better?

Lord Kamall: This is an opportunity to pay tribute to the work of Beat and to remind noble Lords that it is Eating Disorders Awareness Week, and we should be aware of these issues. One of those issues is understanding the different types of eating disorders. Eating disorders is a catch-all phrase and we have to understand that there is: anorexia nervosa, which is more common among people aged eight and over; bulimia nervosa, which tends to affect people at 12 or 13; binge eating disorders, which affect people in adolescence and also their later years—their 30s and 40s; and other atypical eating disorders. It is really important that we understand this and, when we look at training for the general workforce and specialist mental health workforce, that they are more aware of the issues of eating disorders.

Lord Watts: My Lords, if a GP identifies that, for example, a child has an eating disorder, many times they want to refer them to see a psychiatrist. There is an acute shortage of child psychiatrists. What are the Government going to do to speed the process up? It is no use just identifying the problem if you cannot resolve it.

Lord Kamall: The noble Lord is absolutely right; it is not just about understanding the issue but resolving it. Before the pandemic, we were meeting the targets of ensuring that people with disorders were seeing a specialist. Sadly, as a result of the pandemic, we have fallen behind. One of the reasons we are investing extra money in community health for adults and children now is to ensure that we catch up and make sure that people who are suffering with eating disorders are seen by clinicians who understand the issues and the differences between types of eating disorders, so that they are not misdiagnosed or given inappropriate information.

Baroness McIntosh of Hudnall: My Lords, the Minister will know that, although we routinely associate eating disorders with adolescents in particular, they may have roots in adolescence but sometimes emerge very powerfully in later years. They are consequently a lot more difficult to diagnose and manage. The noble Baroness, Lady Parminter, used the word “manage” in talking about how these illnesses should be treated. It is a matter of concern that GPs in particular and hospital services are extremely overstretched. The long-term management of remitting and recurring eating disorders is very hard to sustain. Can the Minister tell us what the Government are doing about that?

Lord Kamall: As a result of the work that has been undertaken in response to the report, and in conjunction with Beat and many other stakeholders, we are looking at the issues. First, we are making sure that people are trained to understand the issues as part of their education. Secondly, we are looking at what we can do retrospectively for those who have already qualified. We are working with various bodies—the royal colleges and others—to see how we can make sure there is more awareness and training available, including e-learning resources.

Baroness Janke: My Lords, there is a need for urgency on this issue. We do not get the impression that the Government are treating this very urgently, but anorexia has the highest mortality rate of any mental illness. If it is not treated early, it becomes worse, much harder to treat and puts lives at risk. In view of the unprecedented growth in sufferers, what will the Government do to accelerate access to treatment for those in urgent need and prevent more needless deaths?

Lord Kamall: I think the noble Baroness is being unfair in suggesting that the Government are not taking this issue seriously. In the conversations that I have had in the lead-up to this Question, it has been quite clear that they are taking it very seriously. They recognise its granularity and the differences in types of eating disorder. As the noble Baroness rightly said, people quite often associate eating disorders with adolescents or young females and young men, but binge eating disorders in particular can occur among adults who are 30 or 40 years old. The Government are looking, first, at education. Secondly, they have made a number of investments in adult and children’s services relating to mental health, including eating disorders.

Baroness Merron: My Lords, there has been a 72% increase this year in the number of children and teenagers referred for urgent support for eating disorders, but a new, dangerous issue has emerged, that of specialist mental health services with no capacity having to bounce back even those who are at risk of suicide, self-harm and starvation to GPs, who, as we have heard, often have no specific training to deal with this. Can the Minister apprise your Lordships’ House of what assessment has been made of the incidence of this so-called bounce-back? Will he commit to tackling it by various means, including a recovery plan for mental health services that has a focus on children and young people and ensures that there is a trained workforce to deliver this support?

Lord Kamall: The noble Baroness’s suggestions are reasonable, and I think that many noble Lords would agree that it is important that we tackle this on a number of levels. For example, under the NHS long-term plan, extra funding has been going to children and young people’s community eating disorder services every year, with £53 million per year invested in 2021-22. That will increase the capacity of 70 new or improved community eating disorder teams covering the whole of the country. In response to Covid and to help meet the waiting time standard, we have invested an extra  £79 million in 2021-22 to significantly expand children’s mental health services. In addition, as part of the additional £500 million that we announced in 2021-22, some of this is also being done via the mental health recovery action plan. NHS England and NHS Improvement have announced a further £40 million in 2021-22 to address the impact of Covid on children’s and young people’s mental health. These are some of the different ways in which we are addressing this very serious issue that a number of noble Lords have quite rightly raised.

Lord Harris of Haringey: My Lords, adolescence has been referred to repeatedly, but does the Minister recognise that there is a gulf between adolescent mental health services and those for adults? A young person reaches the age of 18, ceases to be dealt with through child and adolescent mental health services and is very lucky to get any sort of appointment thereafter. What are the Government going to do about that gulf?

Lord Kamall: There are number of areas—not only eating disorders but elsewhere—where people are often concerned about that transition from children’s services to adult services. We are looking at that holistically to make sure that healthcare is patient centred. It is one of the reasons why we want to make sure that the Health and Care Bill is completely integrated. It will be healthcare whereby the patient is looked after right from their birth all the way through their life, including that transition from children’s services to adult services.

Bus Services: Covid-19 Emergency Funding
 - Question

Lord Berkeley: To ask Her Majesty’s Government what plans they have, if any, to extend the COVID-19 emergency funding for local bus services beyond the end of March.

Lord Snape: My Lords, on behalf of my noble friend Lord Berkeley, and at his request, I beg leave to ask the Question standing in his name on the Order Paper.

Baroness Vere of Norbiton: My Lords, I am pleased to confirm that a final tranche of recovery funding for local transport providers, totalling over £150 million over six months, was announced earlier today. This builds on previous funding packages and will support transport operators and local authorities responsible for bus and light rail systems to transition their networks and adapt to new travel patterns as we build back better from the pandemic.

Lord Snape: My Lords, would the Minister accept that that has rather ruined what would have been a coruscating supplementary on my part? Can I ask her whether she should congratulate my noble  friend Lord Berkeley on his perception in tabling this Question in the first place, and can I tell her that this is the first time in nearly half a century that I have received such a positive response from any Minister in any Government? Perhaps I may ask her to be specific as far as the West Midlands is concerned. Can she offer some comfort to the West Midlands Combined Authority, which estimates a deficit of £50 million in its transport budget for the next financial year?

Baroness Vere of Norbiton: I am always grateful to receive a Question from the noble Lord, Lord Berkeley, but today it was a particularly good one. We will be working with all the local transport authorities as they not only put in place their best service improvement plans, but also make best use of this funding. We have service levels running at approximately 90% while current patronage is approximately 77% and within that there are some quite significant regional variations. For example, we know that in the West Midlands people use buses more than elsewhere. Particularly with the Commonwealth Games coming up, we are very cognisant that we need to keep local transport running.

Baroness Neville-Rolfe: My Lords, I congratulate my noble friend on today’s announcement and the noble Lord, Lord Berkeley. Buses matter a great deal, especially to the elderly and to poorer travellers. Does my noble friend agree that we could do more with technology by drawing on best practice and smartphone ticketing to link buses and coaches to each other as well as to railway stations, trams and city centres, thereby improving value for money and making public transport more competitive?

Baroness Vere of Norbiton: My noble friend raises a very important point which is at the front of the mind of the department: how do we make the best use of technology? It is not necessarily for the Government to step in and develop the technology themselves. However, there are different ways that we see various app providers being able to integrate with multiple transport modes. What we can do is provide them with the data they need for their apps. This is why, a couple of years ago, we launched the bus open data service which puts information out there in an open fashion concerning, for example, routes, live locations of buses, and fares and ticketing systems—the latter can sometimes be very complicated. We hope to simplify that, and we think that the apps can help.

Baroness Randerson: My Lords, today’s announcement is welcome. However, it would have been even more welcome a few weeks ago because the bus industry desperately needs to be able to plan ahead. Does the Minister accept that the industry faces a perfect storm of declining passenger numbers, rising costs and driver shortages? Uncertainty over government funding was an unnecessary additional factor in that. The industry says that it needs over £600 million in order to recover from the Covid situation before we look at the Bus Back Better plans. Does the Minister recognise that this figure is needed?

Baroness Vere of Norbiton: No, I do not. I have not heard the £600 million figure—that is a fair amount. However, I have had numerous conversations with the industry over the months and years during which I have been in post. Some may call it lobbying, and it is very welcome. We have good conversations, and we understand what the challenges are. About 18 months ago I received many questions in your Lordships’ House about how we were going to take into account changes in travel demand as we come out of the pandemic. That is exactly what we must do now. Not every area is going to be the same; there will be changes to patterns of travel. This money will help us to make this transition to what a new future looks like for the bus network.

Lord McLoughlin: My Lords, I draw attention to my interests in the register as chairman of Transport for the North. I welcome the announcement which my noble friend has made today. Will she also give some thought to bringing together all the different kinds of grants made to the bus industry—be it from her department or from the department for levelling up—to show the Government’s commitment to the industry, while also saying that we must move forward with best practice? We are already seeing that in many different cities across the country.

Baroness Vere of Norbiton: My noble friend is quite right. It is extraordinary how many different streams of funding go into the whole bus network system. This can be to the operators directly, or to local authorities—some of which comes from the Department for Transport and some from the Department for Levelling Up, Housing and Communities. I will respond to my noble friend with a letter which draws this all together. It is a substantial sum of money. Combined with some of the money we are putting into the infrastructure of major urban centres—for example, CRSTS—there is a lot of money going into buses, and we need to ensure that we make the best use of it.

Lord Rosser: Will the Minister confirm that none of the emergency support or recovery grants for buses has been taken out of the £3 billion for buses and bus services by 2025 announced under the Bus Back Better strategy, and that all the emergency support and recovery grants are in addition to that £3 billion?

Baroness Vere of Norbiton: The Government have committed to spend £3 billion over the course of this Parliament, so I suggest to the noble Lord that, when we get to the end of this Parliament, we do a totting up.

Lord Beith: My Lords, are any funds for buses and trams on Tyneside being withheld until authorities north and south of the river agree to form a single authority?

Baroness Vere of Norbiton: Yes, there is the question of that; the Government are not withholding the CRSTS funding per se, but we need the governance arrangements to be put into place, such that we are able to distribute that funding to them. We believe that discussions are continuing well.

Lord Watts: I am not sure of the latest figures, but it used to be that something like 70% of the funding for buses came from the public purse. Is it not time that we regulated the buses again to make sure that the taxpayer gets value for money?

Baroness Vere of Norbiton: To a certain extent, I think that is what we are doing, but perhaps not in the way that the noble Lord would expect. The requirement that we set out in the national bus strategy is that every single local transport authority has to have an enhanced partnership, which brings together the right people—the bus operators and local authorities. Managing it from Whitehall is definitely not going to work, but managing it from a local authority level, where local authorities can provide local services for local people in collaboration with bus operators, is what we are hoping to see. We know that the enhanced partnerships will be available in the early part of this year.

Lord Teverson: Will the Minister give us an estimate of when the majority of buses, particularly in city centres, will be decarbonised, running on hydrogen or electricity, so we can get away from these toxic fumes from large quantities of buses in city centres?

Baroness Vere of Norbiton: I agree with the noble Lord. The Government are absolutely committed to pump-priming the zero-emission bus sector. We have £525 million in the kitty to deliver new zero-emission buses. The noble Lord will have seen that the order for Coventry has gone in for 130 buses, and we have announced £71 million for five other areas, for 335 buses, and the orders will go in very soon. But what is the point of all this money—and it is an astonishing amount of money? It is such that we develop the market so that the economics mean that for a bus operator it makes sense to choose a zero-emission bus in future, because it is cheaper and more reliable and provides the level of service that we would expect.

Baroness Deech: Do the Government believe that they have got value for money from the very large grants to Transport for London, given the utter chaos today, which has been met with something of a shrug? Buses are unable to move because of many unnecessary cycle lanes, London is generally in a very poor state—and no one appears to care.

Baroness Vere of Norbiton: My Lords, this Government really do care about what is happening in London. I think that the strike today is unnecessary; it is self-defeating and will damage the job prospects of those who currently are working in what is, in general terms, an excellent transport system. The most recent deal that we did with Transport for London set out very clearly our expectations of the Mayor of London, given his oversight of TfL, to bring forward its modernisation programme, which totals £730 million, but also to look for further savings of around £400 million. That is a lot of money. How was Transport for London allowed to build up such fat?

Sanctions
 - Statement

The following Statement was made in the House of Commons on Monday 28 February.
“With permission, Mr Speaker, I wish to update the House on our support for Ukraine in the face of Putin’s premeditated, pre-planned and barbaric invasion. Ukraine has suffered horrific attacks. Missiles and air strikes have torn through apartment blocks. Tanks have rolled into once peaceful cities. Innocent people, including children, have lost their lives.
The situation is fluid but, as of today, Putin has not taken any major cities. The advance has been slowed by Ukraine’s fierce resistance. Putin’s invasion is not proceeding to plan. He expected to take cities quickly. He expected Ukraine to retreat, and he expected the West to be divided. Instead, his forces were met by the heroism of President Zelensky and the resolute determination of the Ukrainian people. He has been met by a united West, together with our friends around the world, and we have taken decisive action.
Today, we have acted with the US, the EU, Japan and Canada to cut off Russia’s central bank from our markets. The rouble has fallen by more than 40% as a result. As much as $250 billion has been wiped off the Russian stock market and, today, its stock market is closed. The EU, Germany, Sweden and others are following our lead in providing defensive weapons to Ukraine, and Germany has frozen Nord Stream 2.
Putin has been confounded by our collective response. That is why he is resorting to more and more extreme rhetoric. But, of course, the situation remains dire. The Government and people of Ukraine are facing a continued onslaught. The days ahead are likely to prove tougher still.
The UK and our allies will have to undergo some economic hardship as a result of our sanctions, but our hardships are nothing compared to those endured by the people of Ukraine. Casualty numbers are rising, and more than 300,000 people have already been displaced. This is a struggle for Ukraine’s freedom and self-determination, but it is also a struggle for freedom and democracy everywhere and for the survival of a Europe whole and free. We feel a particular responsibility as the UK is a signatory to the 1994 Budapest memorandum, which provided Ukraine with security guarantees.
This premeditated invasion, in violation of international law and multiple international commitments, cannot succeed. Putin must lose. We are doing everything that we can to stop him and to restore Ukraine’s sovereignty and territorial integrity. We will do this by backing Ukraine against unjustified aggression, by degrading the Russian economy and stopping it from funding Putin’s war machine, and by isolating Putin on the world stage.
First, we are backing Ukraine with defensive weapons, humanitarian aid and economic support. The UK was the first European nation to send defensive weapons to the country, and those weapons are being used today to halt Russian tanks and defend Ukrainian towns and cities. Our latest consignment of defensive support left Brize Norton over the weekend. We are  also leading on humanitarian support. Yesterday, my right honourable friend the Prime Minister announced a further £40 million of humanitarian aid, which will provide Ukrainians with access to basic necessities and vital medical supplies. We call on Russia to enable humanitarian access and safe passage for civilians to flee the violence. The UK is also supporting Ukraine’s economy, including through £100 million of official development assistance and guarantees of up to $500 million in development bank loans.
Secondly, we are cutting off funding for Putin’s war machine. We are coming together with the US, the G7 and the EU to take further decisive steps. We have been joined by Australia, Singapore, Switzerland and many more. There is a growing list of countries which are determined that this aggression cannot stand. We have agreed that many Russian banks will be removed from the SWIFT system, kicking them out of international finance. That is the first step towards a total SWIFT ban. Our collective action against Russia’s central bank will prevent it from deploying its international reserves to mitigate the impact of our sanctions.
We are also launching a joint task force to hunt down the assets of oligarchs hit by our sanctions. The UK is proud to lead by example. We have already put in place the largest package of sanctions in our history. We have sanctioned Putin and Lavrov, Russia’s defence industry and a growing list of oligarchs. We have approved asset freezes on several Russian banks and we are banning Russian airlines and private jets from our airspace, but we are determined to go much, much further. We want a situation where they cannot access their funds, their trade cannot flow, their ships cannot dock and their planes cannot land.
Today, I inform the House that I will be laying two new pieces of sanctions legislation. The first will introduce a set of new powers against Russia’s financial sector, including powers to prevent Russian banks from clearing payments in sterling. With over 50% of Russian trade denominated in dollars or sterling, our co-ordinated action with the United States will damage Russia’s ability to trade with the world and, as soon as this legislation comes into force, we will apply it to Sberbank —Russia’s largest bank.
I will also be imposing a full asset freeze on three further banks: VEB, Russia’s national development bank; Sovcombank, the third largest privately owned financial institution in Russia; and Otkritie, one of Russia’s largest commercial banks. We will bring in a full asset freeze on all Russian banks in days, looking to co-ordinate with our allies. The same legislation will prevent the Russian state from raising debt here, and will isolate all Russian companies—more than 3 million businesses—from accessing UK capital markets. Global giants such as Gazprom will no longer be able to issue debt or equity in London.
The second piece of legislation will ban exports to Russia across a range of critical sectors. This includes high-end technological equipment such as microelectronics and marine and navigation equipment. This will blunt Russia’s military-industrial capabilities and act as a drag on Russia’s economy for years to come. I appreciate the consequences of this step for British people and British businesses operating in Russia. The Department for International Trade and the Treasury will offer  advice and guidance to affected UK businesses. My consular staff will continue to support British nationals in Russia, as well as those in Ukraine.
We will keep ratcheting up our response. More legislation will follow in the coming weeks, sanctioning Russian-occupied territories in the Donbass, extending more sanctions to Belarus, and limiting Russian deposits in UK banks. We will continue working through our hit list of oligarchs, focusing on their houses, their yachts, and every aspect of their lives. In addition, we will introduce the economic crime Bill tomorrow; my right honourable friend the Business Secretary will set out more in the next Statement in the House. This is all about flushing out the oligarchs’ dirty money from the United Kingdom. We will continue to work with our G7 allies to cut off the Russian economy and cut the free world’s dependence on Russian gas, depriving Putin of his key source of revenue.
Finally, we are leading the diplomatic effort to ensure that there is a chorus of condemnation against President Putin. In the Organization for Security and Co-operation in Europe, a key part of the European security architecture, 45 countries condemned Russia by name. At the UN Security Council on Friday, more than 80 UN members voted for, or co-sponsored, a resolution condemning Russia’s aggression. Russia stood alone in opposing it. Putin is isolated. No one is willing to back his war of choice. In recent days, I have spoken to my counterparts in more than 20 countries around the world. Yesterday, I met G7 Foreign Ministers. We were joined by Ukraine’s brave Foreign Minister, my friend Dmytro Kuleba. Everyone is clear that Putin must lose, and we will carry on increasing the pressure until he does.
We have all seen Ukraine’s determination to fight. Putin’s war could end up lasting for months and years, so I say to our Ukrainian friends, “We are with you. In Britain, and around the world, we’re prepared to suffer economic sacrifices to support you. However long it takes, we will not rest until Ukraine’s sovereignty is restored. I commend this Statement to the House.”

Lord Collins of Highbury: My Lords, I begin by reaffirming our full support for the Government’s approach to this crisis. On a personal note, I wish to acknowledge the hard work of the Minister, certainly over the weekend, and of his department, in trying to ensure that we get speedy action. The people of Ukraine, led by President Zelensky, have shown incredible resilience. They have the full backing of this Parliament and country in defence of their nation.
There was increasing evidence overnight that thermobaric weapons and cluster munitions are being used by Russian forces, and the number of civilian casualties is increasing by the hour. Given the indication from the ICC prosecutor that they may launch an investigation into claims of war crimes, are the Government considering political and practical support for such a move? I note that Canada has officially petitioned the ICC for an investigation.
Russia’s rejection of international law and the principle of sovereignty must carry fundamental changes for its role in the international rules-based order. That is why we support steps to exclude it from elements of the  international financial system. Earlier today, the Telegraph reported that the UK may push for the suspension of Russia from the UN Security Council. Can the Minister say whether this report is accurate? If so, by what mechanism would the Government pursue this?
The Government must explore all possible avenues to ensure that the Putin regime faces the severest possible consequences. We welcome the sanctions and domestic measures that have already been introduced; I am pleased that legislation on this will progress in the week ahead. Yesterday, the Foreign Secretary said that the department is working through a “hit list” of oligarchs and Duma members to sanction. She also referred to more sanctions on the energy and technology industries. Is the Minister in a position to report on these further designations and when they may come into force? I was pleased to hear that she wanted to see a total ban on SWIFT transactions, encouraging allies to back it, together with a full bank freeze, in the coming days. Can the Minister update the House on such measures?
In the debate we held on Friday, the Minister acknowledged the strength of feeling in this House on expediting the full economic crime Bill. It is vital that we act now on corrupt Russian money; ending the impunity that oligarchs have enjoyed for too long and reforming Companies House to crack down on shell companies that hide suspect wealth are vital actions that we should speedily adopt.
In addition to our lethal aid supplies, it was welcome news on Sunday that the European Union will fund the delivery of weapons to the Ukrainian Government. The EU foreign affairs chief, Josep Borrell, said that planes would be transferred to the Ukrainian air force, alongside deliveries of small items such as shoulder-fired anti-tank and anti-aircraft missiles to the Ukrainian army. I hope the Minister can confirm that we are working closely with the EU to ensure that, together, we meet the request from President Zelensky’s Government on these weapons.
Sadly, the human cost of this crisis will worsen as Putin continues his indiscriminate shelling. This is already leading to the displacement of people into eastern Europe. The UN Refugee Agency said this morning that 660,000 Ukrainian refugees have fled since the invasion last Thursday. I know the Government announced today that the UK’s Ukrainian refugee scheme will now be extended to wider family members. As my right honourable friend Yvette Cooper said earlier in the Commons, many Ukrainian families want to stay close to home but
“for those who want to travel to the UK to seek shelter with family or friends and get the support they need at this dreadful time, we must be ready to help.”
These Benches have been calling repeatedly on the Government to do more to help. There will be considerable relief that they have now changed their position and accepted that we must do more.
However, for the many who are unable to leave, we should prepare to provide urgent humanitarian support. I very much welcome the announcement of the UK’s first humanitarian aid package to Ukraine. I hope the Minister can confirm whether the Government have experienced any difficulties with the delivery of that  aid and what we are doing to overcome such difficulties. Are we preparing for the humanitarian consequences of the sieges in Kharkiv and Kyiv?
The Government will have our full support on any steps taken to secure the territorial integrity of Ukraine and the measures introduced so far are welcomed by all sides of the House. It is now clear that the people of Ukraine are prepared to resist Putin’s aggression and, while Russia’s advance may have been limited so far, he will no doubt escalate his campaign of violence. The challenge for us as a country and our allies is to ensure that these acts of barbarism have unbearable consequences for Putin and his role in the world.

Lord Purvis of Tweed: My Lords, these Benches also welcome the proposals and will work constructively with the Government to see them properly enforced. I also commend the Minister for the conscientious way he carries out his duties and his contact with the Front Benches—it is appreciated.
Last week, I was in Baghdad and then Beirut, where wounds of conflict are still not fully healed and where there was palpable shock at the grotesque and wanton destruction inflicted by the now pariah regime of Vladimir Putin and his desire to crush and subjugate a democratic European nation. Within Ukraine, areas I have visited and neighbourhoods of people I have met and know are being systematically targeted in premeditated and gross violations of international law and human rights norms. Will the UK fund and prepare a team of expert investigators and jurists to support the collection of evidence for pursuing human rights violations in The Hague against the Putin regime?
It was a solemn but nevertheless proud moment yesterday when President Zelensky’s party, Sluha Narodu, became an affiliate member of the Alliance of Liberals and Democrats for Europe, the sister party of us in this House. It draws attention to the fact that the democrats and President Zelensky in particular are now a beacon of democracy and hope in this continent. The president of the General Assembly of the UN, Abdulla Shahid, said yesterday that Russia’s actions are
“an affront to the founders of this organization and everything it stands for.”
The challenge ahead is immense. The Government need to continue to raise their game, and we will work with them in so doing.
The Government’s Statement indicated that the humanitarian assistance was £100 million of ODA and guarantees of up to $500 million in development bank loans. The UK does not provide development bank loans, so I assume this will be done through the World Bank. Last year, the Government cut contributions to the World Bank development bank by 25% and I do not think there is an increase to the Government’s 0.5% cap on international development assistance. Can the Minister confirm that support for those who are suffering in other conflict zones, such as Yemen, will not be squeezed in order to provide much-needed support for Ukraine?
The Government have acted to expand the visa scheme for those seeking refuge and safety in the UK but, as the noble Lord, Lord Collins, indicated and as  this House very clearly indicated yesterday, we are not happy that the Government was restrictive. More needs to be done in this field.
We welcome the draft economic crime Bill to complement this work but have major concerns that the lack of resources provided to the NCA, the CPS and Companies House, to ensure that existing laws are enforced, will not be reversed. This new legislation will require new resources to ensure that measures are robustly enforced. Can the Minister commit to this? We should use the laws we have in place now to take action and ensure law enforcement are given the resources immediately to do so.
The Statement indicated that we would be moving on Belarus sanctions “in the coming weeks”. I appeal to the Minister. The Belarus regime is now fully complicit with the Russian regime in this conflict, and therefore it is obvious that the actions against Russia should now apply to Belarus. Here at home, can the Government make sure that there is urgent action to ensure that enablers who have supported the oligarchs will not be able to profit from any delay to the bringing forward of new legislation? There is an energy carve-out in the SWIFT restrictions and the banking restrictions. Can the Government use urgent anti-avoidance measures now in the City of London to ensure that lawyers, accountants and financiers will not profit from any delay before legislation is implemented?
Finally, the response of the EU, the US and the UK and others around the world has shown that we, working in co-operation and partnership, stand against illegal aggression and the increasingly desperate narrative of misinformation and disinformation from the Kremlin. We need immediacy and urgency in our actions here at home to support the call of the President of the United Nations General Assembly yesterday to return to peace.

Lord Ahmad of Wimbledon: My Lords, I first thank both noble Lords for their strong support for the Government’s position. Indeed, I thank all noble Lords who have shown without any hesitation full support for the position that the Government are taking. As I said before, this is the position of a united United Kingdom, and I am grateful for the support.
I thank the noble Lord for his kind remarks. However, as I have said before, it is important to respond by saying that the challenges we may face as Ministers, shadow Ministers or in your Lordships’ House pale into insignificance when we see the challenges faced by the Ukrainian people. I agree with the noble Lord, Lord Collins, about the exemplary way in which President Zelensky is conducting himself. If there is a great example of modern-day leadership, he very much epitomises that. Earlier today, on my return from Geneva last night, I—like other noble Lords, I am sure—heard his very emotional address to Members of the European Union Parliament. It was not a scripted speech; he was speaking from the heart and reflecting the sentiments of the Ukrainian people. I thank the noble Lord, Lord Collins, and the noble Lord, Lord Purvis.
I know that the noble Baroness, Lady Northover, was also travelling over the weekend. We worked on a particular issue and I am grateful for the information she provided, which allowed us to expedite a particular issue in response to the Ukrainian crisis.
On the issues that the noble Lord, Lord Collins, raised, first, on the issue of the ICC prosecutor Karim Khan, yesterday while I was in Geneva I received a call from him. Today, to quote the statement he issued, he expressed his concerns,
“echoing those of world leaders and citizens of the world alike, over the events unfolding in Ukraine. Today, I wish to announce that I have decided to proceed with opening an investigation into the Situation in Ukraine”.
Of course, I assure both noble Lords that we will be co-operating with the ICC.
On the issue of the financial systems and other sanctions that have been announced, today has been a busy and rightfully important day when it comes to the United Kingdom’s response. If I may seek the House’s indulgence, we have seen announcements from the Home Secretary, the Transport Secretary, and indeed further announcements from the Prime Minister.
This is a fluid situation, so I express my apologies, as things are happening and we are trying to update. Events on the ground are extremely serious; reports are now coming in that the Russian army is moving forward on Kyiv. We are monitoring that very closely, working across government and, I assure both noble Lords, with all partners, including, importantly, our European partners. As noble Lords will be aware, my right honourable friend the Prime Minister is visiting Poland today, as well as Estonia, which underlines our commitment to work directly with our European partners but also the importance of the NATO defence alliance. My right honourable friend the Prime Minister is in regular contact with President Zelensky.
Today we have also made further regulations that introduce new measures that prohibit financial transactions with the Central Bank of the Russian Federation, the Russian Ministry of Finance and the Russian National Wealth Fund. These have been laid—I understand the usual channels will be in touch—and we will work through the appropriate debates on this later in the week.
My right honourable friend the Home Secretary— I gave this assurance to your Lordships’ House on Friday, when we had a debate on Ukraine—has made further announcements from the Home Office. Contingency plans are now fully effective, and she introduced new measures today, which were announced in the House of Commons, and has established an expansive Ukrainian family scheme. The scheme will be free, and those joining their family will be granted leave for an initial period of 12 months. Within this, they will be able to work in the UK and also access public funds. Secondly, there is the establishment of a humanitarian sponsorship pathway, which will open a route to the UK for Ukrainians who may not have family ties with the UK but who are able to match with individuals, charities, businesses and community groups in support of their presence here. Those who come under this scheme will also be granted leave to remain for an initial period of 12 months and be able to work and access public services. I mention those few key bullet points to highlight that substantial progress is being made.
On the issue of continuing support, which the noble Lord, Lord Purvis, raised, I assure him that we are going through the final rounds of our support for particular areas of the world, including Afghanistan,  which I have been involved with. We remain very much focused on the humanitarian situations around the world, and I look forward to an update from him on his recent visits to both the Lebanon and Iraq.
My right honourable friend the Prime Minister has also announced additional funding. A release is being worked through, but I can share with your Lordships’ House that we initially stood up immediate emergency funding in the region of £8 million, but that has been increased substantially, and the overall economic and humanitarian support package now stands at £220 million, and £120 million of that is specific to humanitarian support.
I was in Geneva yesterday and met Filippo Grandi, who heads the UNHCR, and today my right honourable friend the Foreign Secretary also met him. An announcement is being made by OCHA through Martin Griffiths of a funding requirement and a new ask for funds to respond to this emergency. Of course, the UK is working very closely on that, and my right honourable friend the Foreign Secretary reiterated that in her meeting in Geneva today.
On the issue of the economic crime Bill, I listened carefully to what the noble Lord, Lord Purvis, said. The sentiments of your Lordships’ House have been reflected in how we have worked on it, and I am sure that noble Lords welcome the commitment that the Government have given in the Bill. I hear what the noble Lord says about Belarus, and we have increased the resource of our sanctions team. As the Sanctions Minister, I can speak from direct insight on how hard the team is working to ensure that we meet directly the requirements. There is still more to be done in this respect.
We campaigned very strongly on the issue of SWIFT, which led to the specific first step taken to exclude certain banks and institutions from the SWIFT payment system, and we continue to work on that.
We have also made an important announcement in the area of transport. Today, we have implemented a set of new transport sanctions which will prohibit Russian ships and other ships specified by the Secretary of State from entering ports in the United Kingdom. I believe that we are the first country to introduce such specific restrictions.
On defence co-operation, President Zelensky and Foreign Minister Kuleba have acknowledged that we have been one of the first countries to offer support in the form of military equipment required by Ukraine, and we continue to work in that respect.
My final point to noble Lords on the Front Bench and across your Lordships’ House is that the situation within Ukraine is very difficult. Yesterday, I met various humanitarian agencies that are working on the ground, some of which I will not name for their protection. They are still very much concerned with the issue of internal displacement and also that they do not know what the situation is in the various sieges that have been laid to towns. I know from the regular contact we are having with Foreign Minister Kuleba and President Zelensky through my right honourable friends the Foreign Secretary and the Prime Minister, my right honourable friend Minister Cleverly, the Minister for Europe, and me directly, that we are ensuring that we  focus our support in the best way possible, led by the priorities needed as, today, we stand by the Ukrainian people and their Government.

Lord Howell of Guildford: My Lords, my noble friend the Minister will have noticed that, on Friday, China and India—in fact, the UAE as well—refused to condemn outright the Russian bloody assault by abstaining. Has he also noticed that China and India are, I am afraid, busy preparing special payments arrangements internationally with Moscow to avoid the effect of the sanctions we are seeking to apply? Perhaps China is beyond reach in this matter, but surely, we have some alliance and understanding with India. Can we not persuade India to join the rest of the democracies—it is the world’s greatest democracy, after all—before it goes on this path, which will be very damaging to our cause?

Lord Ahmad of Wimbledon: My Lords, I assure my noble friend that, at both the UN in New York and the Human Rights Council in Geneva, two resolutions are currently tabled. We are working on an extensive lobbying campaign to ensure maximum support for the two Ukraine resolutions in both places.
On my noble friend’s point about the UN Security Council, he is of course correct that three countries abstained, and Russia also vetoed the resolution that was passed. We are dealing directly with and making our case to not just the UAE and India but China as well. Indeed, in terms of our lobbying effort through our ambassador and the team on the ground in New York, we were pleased that China did not veto the UN security resolution but abstained instead.
My noble friend makes valid points on India, and I know for a fact that my right honourable friend the Prime Minister will speak with Prime Minister Modi today or tomorrow.

Lord Alton of Liverpool: My Lords, on the question of justice and war crimes, does the Minister recall the calls made in your Lordships’ House on Friday last for a referral to the International Criminal Court? Indeed, has he had a chance to read the letter that was signed by a number of distinguished Members of your Lordships’ House and sent to Karim Khan QC, the prosecutor at the ICC, over the weekend? In addition to what he has told the House about what Karim Khan said in his statement, did the Minister read these words:
“There is a reasonable basis to believe that both alleged war crimes and crimes against humanity have been committed”
in Ukraine? As well as the importance of bringing Putin to justice, is it not right that we do as the noble Lord, Lord Collins, said and salute the courage and bravery of President Zelensky? Also, is it not particularly offensive to hear Putin and the Kremlin describe him as a Nazi when you consider that his grandfather had three brothers who were murdered by the Nazis in the Second World War?

Lord Ahmad of Wimbledon: My Lords, I am sure I speak for the whole House when I say that in President Zelensky we see someone principled who is  standing by his people. I remember that my last visit to Ukraine took place at the exact time of the marking of the Holocaust, which engulfed the Ukrainian people. President Zelensky is the grandson of someone who survived the Holocaust, so let us reflect for a moment on that. I say to those who accuse him of Nazification: his grandfather was a survivor of those evil Nazi acts.
The noble Lord referred to Karim Khan, the ICC prosecutor. In Friday’s debate, I said that many people around the world should perhaps reflect on what was being said in your Lordships’ House and the quality of the contributions, for it was a debate informed by and based on expertise, insight and experience. As I said, I had a conversation with Karim Khan yesterday and we exchanged messages today. I have seen his full statement, which includes the words articulated by the noble Lord. He is looking specifically at that referral mechanism.

Lord West of Spithead: My Lords, do we and our allies have a view of what a satisfactory end state would be for us? Do we have a mechanism for stopping the sanctions, or some of them? We have a bad track record of doing that in the past. For example, is it just a case of saying, “Get out of Ukraine”? If so, does that include the Donbass, Crimea, Georgia, Moldova, Donetsk and Abkhazia? We must have a view of where we want to go and what we want. Do we have that clear view, and do our allies have it?

Lord Ahmad of Wimbledon: My Lords, the noble Lord makes an important point. Of course, the clear view has to be led, and rightly so, by the Ukrainian Government and the Ukrainian people. They have kept the issue of diplomatic negotiation very much open. Yesterday, President Zelensky, notwithstanding his own assessment of what the outcome would be of those negotiations, sent a team to the border with Belarus to meet directly with Russian representatives. I have seen the statements that came out of that, and they probably reflected President Zelensky’s pessimistic view. Our view is clear and is shared by the Ukrainian Government. Yes, ultimately, there has to be a peaceful settlement, but to allow diplomatic means to prevail, President Putin must pull back from the eastern part of Ukraine to allow those discussions to take place. To set preconditions while occupying sovereign land is no way to say, “Let’s seek a diplomatic solution.”

Baroness Warsi: My Lords, can my noble friend clarify the position of British citizens—civilians—who may wish to travel to the Ukraine to fight, as there has been some mixed messaging from the Foreign Office? That would greatly assist those who are keen to help Ukraine, but who would be endangering themselves and Ukrainians if they were to take that position.

Lord Ahmad of Wimbledon: My Lords, my noble friend is right to draw attention to this. Of course, the sentiments of your Lordships’ House reflect those of any person with humanity at their core: you want to help in the best way possible. The best advice that I can offer to anyone seeking to travel to Ukraine is to look at the Foreign Office advice, which is very clear: do not travel to Ukraine. There is a lot that you  can do within the United Kingdom to provide support, and we are extending support to near neighbours as well. They may wish to help with humanitarian efforts, but the situation in Ukraine is very fluid. We are recommending that no one travel there, and I hope that this Foreign Office advice is heeded.

Lord Tyrie: My Lords, what lessons do the Government draw from the fact that on sanctions, the supply of arms and the treatment of refugees, the UK, like the leaders of many western European countries, is being pushed by public opinion into much more far-reaching support for Ukraine than those leaders had originally intended? Does that not strongly suggest that further measures should be taken and more support given to Ukraine and to Zelensky’s Government?

Lord Ahmad of Wimbledon: My Lords, I can certainly speak for the United Kingdom Government. For example, through Operation Orbital we were providing defence support directly to Ukraine immediately after the occupation of Crimea. We have a long-standing relationship with Ukraine: indeed, President Zelensky and Foreign Minister Kuleba have talked of the strong support they have received from the United Kingdom over a number of years. However, I acknowledge that when there is a crisis of the magnitude we now see in Ukraine, with the sovereignty of Ukraine being directly usurped by Russia, it is right that we, the Europeans, and all international partners look to do what we are doing, and do more. There is more still to be done.

Lord Wallace of Saltaire: My Lords, I think that everyone in this House would like to compliment the Minister on the enormously valuable work he has done and continues to do on this; we all appreciate it. However, can he take back to his colleagues that saying all the time that we are leading on this and leading on that is not the right tone? To say that we are working with others, we are co-operating, we are in solidarity with our partners and allies would be much more constructive in the current context.
Can I also ask about the domestic dimension of sanctions? I was very struck by the paragraph in the Intelligence and Security Committee’s Russia report which said that the penetration of British society and politics by wealthy Russians resident in London has gone so far that it is now in some ways difficult to untangle. We must now see what we can do to untangle that. Can we be assured that the Government will not only do their best to untangle it, but report to Parliament on what they are doing?

Lord Ahmad of Wimbledon: My Lords, on the noble Lord’s second question, perhaps I can answer it with his first suggestion. To untangle such challenges we must work together, which is exactly what we are doing. We are working here in the United Kingdom and with key partners to negate the negative influence of Russian money and illicit finance in the United Kingdom and more broadly. As he will have seen from the sanctions we have introduced, they are reflective of that very objective. I am sure he will find that, as further legislation comes forward, further sanctions are applied and we have discussions on the economic crime Bill, we can untangle some of those issues.
On the issue of leadership, I have served with the noble Lord in government and I am sure he agrees that there are times when the United Kingdom leads the way, and I am proud of that. The richness of our history, our experience and our expertise reflects that. It is that leadership which also leads to enhanced partnerships, and that is exactly the approach we have adopted in this crisis.

Lord Browne of Ladyton: My Lords, I welcome the Statement. It is certain that cryptocurrency will be used extensively to at least attempt to avoid these sanctions. There is no question about that. I think the Government are alert to that; the Foreign Secretary’s answers in the other place certainly indicated that they were. For the second day in a row, can I try to persuade a Minister to get the Financial Conduct Authority—
“the anti-money laundering and counter-terrorist financing … supervisor of UK cryptoasset businesses”
under the money laundering regulations—to remove the list of non-compliant crypto- asset dealers from its website? It is advertising money launderers to crooks and kleptocrats. Can they please be removed? There are 220 of them. It is not just their names: their websites and sometimes their mobile phone numbers are there.

Lord Ahmad of Wimbledon: They say that when you say it once, you say it twice; I hope the noble Lord might not need to say it thrice. I certainly note very carefully what he said. Of course, cryptocurrency provides an opportunity to weave a way out of some of the sanctions restrictions that are being applied, as he rightly articulated. I noted very carefully what he said and I will respond with more detail in due course.

Lord Mackay of Clashfern: My Lords, I think that a Russian oil tanker was expected today in Orkney. There was some question about whether it had been sanctioned. I wonder whether the Minister can resolve that point, which is rather important, because Orkney is of course a very important part of the world.

Lord Ahmad of Wimbledon: I cannot answer specifically on that vessel. It depends on what time it came in, because the measures announced by my right honourable friend the Transport Secretary came into force at 1500 hours. It really depends on where the vessel was when those sanctions came into force.

Lord Hogan-Howe: My Lords, I am no lawyer, but it seems that this is an illegal war. We have used sanctions, properly, to try to influence a Government and a country to stop invading another country and to stop military people carrying out their tasks. We have now moved to a time to try to influence the people on the ground. That means the actions of either military or intelligence leaders. I follow the point from the noble Lord, Lord Purvis, that investment in our ability to investigate crime would be wise, but also in international prosecutors and the investigation they are about to embark on. The time is now to collect digital evidence on the ground to influence soldiers there, to stop them carrying out barbaric acts if we can and either publish  their faces or identify them now, because an investigation after the event will be too late to prevent the damage they might cause today. It is clear that we will see conflict between military people and civilians over the coming days. This is the time to try to influence that behaviour. The digital world is just one way to achieve it.

Lord Ahmad of Wimbledon: My Lords, the noble Lord makes a very practical and helpful suggestion. We are collecting evidence to support whichever jurisdiction might follow through on the crimes being committed on the ground, including those that will be investigated by the ICC. We will be in full support of that with whatever evidence we have; we will submit our own intelligence that we gather on the ground. Equally, as he may well be aware, we are a strong supporter of the ICC. We will work co-operatively with whatever evidence we can provide to it.

Lord Cormack: My Lords, my noble friend made several references to legislation. Does he accept that it would be right for such necessary legislation to be given priority over all other legislation? It is absolutely essential that we spend our time dealing not just with domestic Bills if there are Bills that can have a real influence on this ghastly situation.

Lord Ahmad of Wimbledon: My Lords, on the immediate issue of the sanctions, we have been working through the legislation, and I am grateful to the usual channels. Normally, there is a 28-day period for a debate to prevail after legislation has been laid; we are currently conducting the debates within 24 or 48 hours, so that partly reflects the situation. On the wider legislation we are bringing forward, I know the respective Front Benches and the usual channels are working very hard to accommodate the legislation required.

Baroness Meyer: My Lords, I too congratulate the Government on all that they are doing for the Ukrainian people. Given that the oligarchs who are close to Putin use lawyers, tax advisers and other such people, what can the Government do to force them to release any information that would follow the money? To be honest, a lot of the money is Putin’s, and he uses oligarchs to move it around.

Lord Ahmad of Wimbledon: My Lords, my noble friend again raises an important point. In our debate on Friday, the noble Lord, Lord Carlile, also raised the point that the oligarchs are extremely wealthy and can employ lawyers to good effect. That is why our sanctions regime is both robust and tested in terms of legal thresholds before it is applied, to minimise any litigation that may take place.

Lord Teverson: My Lords, is the Minister having sufficient conversations with our overseas territories and Crown dependencies to make sure that none of our financial sanctions is bypassed in any way?

Lord Ahmad of Wimbledon: My Lords, this question has come up before—I believe that the noble Lord, Lord Wallace, asked it too. The legislation will  take effect directly in our OTs as well. Of course, my right honourable friend Amanda Milling, the Minister with responsibility for the overseas territories, is dealing directly with the OTs on this.

Lord McDonald of Salford: My Lords, the noble Lord, Lord Collins of Highbury, mentioned the interest in depriving Russia of permanent membership of the Security Council. Can the Minister confirm that the arrangement made in December 1991, supervised by my noble friend Lord Hannay of Chiswick, to have Russia as the successor state to the Soviet Union is legally watertight, so that the only way Russia can be deprived of permanent council membership is if Russia votes in favour of it?

Lord Ahmad of Wimbledon: I think the House will take the lead of the noble Lord who, as a very distinguished former Permanent Under-Secretary at the Foreign and Commonwealth Office, speaks to what the requirements are. This has been the challenge, frankly, at the Security Council. I am proud—if I may use the word—of the UK’s leadership in its lack of use of its veto power, unlike other P5 countries. The noble Lord is correct in that respect. However, we have seen other actions; for example, the Foreign Minister of Russia could not travel to Geneva for the Human Rights Council earlier today. For those who say the sanctions are not working, I point out that the logistics of restrictions on Russian-registered aircraft over certain countries prevented him travelling. When he spoke, a majority of delegations left the room. There are measures or stands that you can take within the diplomatic network that show not just your immense dissatisfaction but your rejection of the actions of a member of the permanent five.

Lord Sterling of Plaistow: My Lords, has my noble friend the Minister had conversations with the P&I clubs? As we sit here, loads of tankers are leaving every day with oil for Russia. If you take away the insurance of the tankers themselves, and what they are holding for the owners, that could disrupt them hugely in making the dollars that they much like to make.

Lord Ahmad of Wimbledon: My noble friend speaks with detailed insight of the industry. I have gone through, at a summary level, what the new transport measures will mean. I will of course reflect on what he said and then write to him specifically on whether those prohibitions will apply. The fact that Russian ships cannot now enter any British port since 3 pm today will partly address the question he put to me.

Baroness Foster of Oxton: My Lords, as on other days, today we are witnessing acts of genocide and war crimes against the women and children of Ukraine, and we know that Putin’s ambitions will not stop there. At the same time, we have a phenomenal amount of air power just sitting on the ground across Europe. Notwithstanding the time it would take for sanctions to kick in, what exactly would it take for NATO to take direct action to stop Putin in his tracks?

Lord Ahmad of Wimbledon: My Lords, my noble friend talks of air power. One thing is very clear: we fulfil our obligations through NATO. As my right honourable friend the Prime Minister said in response to a question put to him today, we are not in the position of putting in place measures that provide the basis for British military aircraft conducting combat directly with Russian combat aircraft. At this juncture of the conflict, our support is very much to the defence of Ukrainian sovereign territory. My right honourable friend has made it clear, as has my right honourable friend the Defence Secretary, that we stand solidly behind the defensive support we can give to Ukraine. We are also providing training support and other defensive material.

Health and Care Bill
 - Report (1st Day)

Relevant documents: 15th, 16th and 19th Reports from the Delegated Powers Committee, 9th Report from the Constitution Committee

  
Schedule 1: Renaming of NHS Commissioning Board

Amendment 1

Baroness Penn: Moved by Baroness Penn
1: Schedule 1, page 139, line 29, at end insert—“the Armed Forces Act 2006, section 343AA (as inserted by section 8(3) of the Armed Forces Act 2021);”Member’s explanatory statementThis amendment is consequential on Clause 1 of the Bill which renames the National Health Service Commissioning Board “NHS England”.

Baroness Penn: My Lords, in moving Amendment 1, tabled in the name of my noble friend Lord Kamall, I will speak to the other government amendments in this group in his name.
Amendments 1, 76 and 77 are consequential amendments to two pieces of legislation that have been before Parliament during this Session. These amendments relate to the Police, Crime, Sentencing and Courts Bill and the Armed Forces Act 2021, and replace references to clinical commissioning groups with references to integrated care boards, and references to the NHS Commissioning Board with references to NHS England. Amendments 110 and 126 are purely minor and technical in nature to correct small drafting points in Clause 79 and Schedule 16.
I turn now to capital expenditure. The Government have listened carefully to the debate on Clause 54, and Amendments 88 to 91 will ensure that the powers in Clause 54, alongside our commitments to publish further operational guidance, are in line with the agreement between NHS Providers and NHS England in 2019. These amendments limit the powers to set capital expenditure limits for NHS foundation trusts, so that they cannot apply for periods longer than a financial year.
NHS England will continue to work with NHS trusts and foundation trusts to ensure sustainable use of capital expenditure, and it is our intention that a capital limit would be imposed only if other ways of resolution have been unsuccessful. A limit would be set only where usual financial reporting returns identify a likely breach of system expenditure limits. We therefore expect that the vast majority of capital limits will be set either in-year or shortly before the beginning of a financial year.
I reaffirm the Government’s commitment to ensuring that these powers are used only as a last resort, as NHS England agreed with NHS Providers. I am grateful to both NHS Providers and the noble Lord, Lord Crisp, for their constructive work in ensuring that these powers reflect that intention.
I hope noble Lords will therefore be supportive of these amendments. I beg to move Amendment 1.

Baroness Walmsley: My Lords, I thank the Minister for explaining the government amendments. I particularly welcome Amendments 88 to 91, because the Bill will now reflect the agreement made with the NHS foundation trusts in a much closer manner than in its original drafting. They are very welcome.

Lord Crisp: My Lords, I echo that statement and say how much I appreciate both the way in which the discussion was held and the end point whereby these amendments have now been placed in front of us.

Baroness Thornton: I absolutely concur with the noble Lord, Lord Crisp, and the noble Baroness, Lady Walmsley, and congratulate the Minister on a concise and accurate proposal of these amendments. Long may this continue.

Baroness Penn: My Lords, this has been a welcome, consensual and short start to Report stage, which I am sure we will continue through future groups. I am not sure there is much to add, so therefore I ask that these amendments be agreed.
Amendment 1 agreed.

Amendment 2

Lord Kamall: Moved by Lord Kamall
2: After Clause 2, insert the following new Clause—“Spending on mental health(1) The National Health Service Act 2006 is amended as follows.(2) After section 12E insert—“12F Expected mental health spending(1) The Secretary of State must, in respect of each financial year, publish and lay before Parliament a document—(a) stating, by comparison with the previous financial year—(i) whether the Secretary of State expects there to be an increase in the amount of expenditure incurred by NHS England and integrated care boards (taken together) in relation to mental health, and  (ii) whether the Secretary of State expects there to be an increase in the proportion of the expenditure incurred by NHS England and integrated care boards (taken together) that relates to mental health, and(b) explaining why.(2) The Secretary of State must publish and lay the document before the financial year to which it relates.”(3) In section 13U (annual report), after subsection (2A) (inserted by section 29 of this Act) insert—“(2B) The annual report must include—(a) a statement of the amount of expenditure incurred by NHS England and integrated care boards during the year (taken together) in relation to mental health,(b) a calculation of the proportion of the expenditure incurred by NHS England and integrated care boards during the year (taken together) that relates to mental health, and(c) an explanation of the statement and calculation.””Member’s explanatory statementThis amendment requires the Secretary of State to publish any governmental expectations as to increases in mental health spending by NHS England and integrated care boards, and requires NHS England to include in its annual report information about such spending.

Lord Kamall: My Lords, in moving Amendment 2, I will speak to Amendments 57, 78 and 109 in my name. We have heard impassioned and compelling arguments here and in the other place for the need for greater emphasis on mental health in the Bill. We have listened and, as a result, have taken action. The result is the package of amendments brought before the House today. I take this opportunity to pay tribute to the many noble Lords across the House who have contributed to the development of these amendments and the advice we have received.
Let us first turn to defining health. I assure your Lordships’ House that this Government remain fully committed to delivering parity of esteem between physical and mental health. We want to support everyone’s mental health and well-being. We are very aware of the impact that the pandemic has had on a number of individuals and communities, particularly the impact on mental health and mental health services.
Amendment 109 removes any potential confusion as to whether references to health within the NHS Act 2006 include mental health. We have made it absolutely clear with our amendment that references to health includes mental health as well as physical health. I know noble Lords will acknowledge that it was our view that the current references to health in the Act would have included mental health, but this amendment is important because it sends a strong signal that health must not just be associated with physical health. Mental and physical health are equally important, and our legislation reflects that fully.
On the transparency and accountability of mental health funding, the Government remain committed to our ambitions in the NHS Long Term Plan to transform mental health services in England. The NHS Long Term Plan committed to increase spending on mental health services in real terms by at least £2.3 billion a year by 2023-24. For each year of the current spending review period, the spend on mental health will increase  as a share of the NHS budget. This is in line with the Government’s ongoing commitment to grow investment in mental health services faster than the overall NHS budget. Our amendment seeks to bring added transparency to this commitment and will better enable Parliament, stakeholders and the public to hold the Government to account for meeting this commitment.
The Secretary of State will be required to publish and lay before Parliament, before the start of each financial year, a document setting out the Government’s expectation on mental health spending for the year ahead. This document, a Written Ministerial Statement, will set out whether the Secretary of State expects there to be an increase in the amount and proportion of expenditure incurred by NHS England and integrated care boards, taken together, in relation to mental health, with a supporting explanation. There will also be requirements for NHS England and ICBs to include in their respective annual reports information about such spending to clearly demonstrate performance against expectation.
I am very grateful to the noble Lord, Lord Stevens, as well as the noble Baronesses, Lady Hollins, Lady Merron and Lady Tyler of Enfield, for supporting amendments related to transparency and accountability of mental health funding in Committee, and for their constructive engagement since. I hope I have reassured noble Lords that this Government are committed to delivering parity of esteem between physical and mental health. I hope that our amendments address the issues and concerns previously raised and that the House will pass them today. I beg to move Amendment 2.

Lord Stevens of Birmingham: My Lords, continuing the outbreak of consensus, a large number of mental health stakeholders welcome the fact that the Government have accepted these amendments, which draw heavily on amendments a number of noble Lords brought forward in Committee. I think I said at that point that they would represent a spine-stiffener for the Government in their commitment to ensure that mental health sees a growing share of the growing NHS budget and an accountability booster for the NHS. I think they do that.
However, before the Minister concludes on this item, will he say whether, when setting the mandate for NHS England for the financial year ahead—the mandate that will therefore be laid at some point within the next 30 days—the Government might set the mental health waiting time standards, the very welcome consultation on which concluded last week, in a way that other amendments in this group would look to advance? None of that should detract from the fact that these amendments have wide support outside this place and will make a real difference to mental health in the years to come.

Baroness Tyler of Enfield: My Lords, I rise to speak to Amendment 184, tabled in my name. I shall first respond briefly to the government amendment introduced as a result of the discussions in Committee, which set the context for my amendment. I welcome the government amendment requiring the Secretary of State to publish his expectations about increases in the amount and proportion of mental health spending by  NHS England and ICBs. I also welcome amendments requiring NHS England and ICBs to include information about spending relating to mental health in their annual reports.
However, it is stating the obvious to point out that their ability to do so is ultimately reliant on the Government—that includes the Treasury—prioritising sustained growth and investment in mental health. This is critical to avoid a widening care deficit in mental health and inequity between physical and mental health care standards. When I say “a care deficit” I want to explain briefly that the healthcare system is still operating in the context of a mental healthcare deficit, where not all those who need help and treatment will seek it or be able to access it and it is estimated that 1.7 million people are waiting to access mental health services.
That is the context of my Amendment 148. It is designed to build on the welcome government amendments and to provide what I call the critical third pillar of reform, which is service access standards. I welcome the measures that the Government have already taken in relation to access standards as part of the NHS long-term plan, but I believe we need to go a bit further and give them more teeth. Waiting time standards can play a critical role in making progress towards our shared ambition of achieving parity of esteem, particularly in service response times. Standards are a driver to secure the resources needed for services to be able to meet demand in an effective and timely way.
Key to the successful implementation of the service access standards will be two things: first, the funding to develop services in a way that means they can meet these standards without leading to unintended consequences, such as transfer of delays from accessing the system to further down the care pathway; and secondly, a clear expectation that these standards must be matched with a sufficient workforce so that the standards are delivering better care and not shifting problems further down the line.
Having these service access and waiting time standards underpinned by legislation would be a very effective lever for improvement by helping to identify where additional resources are needed. I have looked very carefully at the two points in the response published last week to the consultation on NHS access standards. I think the key points were clear: new targets cannot be introduced without additional funding to support them; respondents were generally strongly supportive of new targets in mental health; quality as well as speed of response is important; and expanding the range of the targets to include preventive and early intervention services would be beneficial.
I took heart from the news release that accompanied the publication of that response. I saw that the Minister for Mental Health, Gillian Keegan MP, said:
“Improving access to mental health services is a top priority. These new standards would help patients get support faster—including having a face-to-face assessment within one hour of being referred from A&E. I know there is more to do and that’s why we’re transforming mental health services in England with an extra £2.3 billion a year and will soon be launching a national conversation to inform a new long term Mental Health Strategy later this year”.
That is all very welcome. With such an endorsement from the Minister in the other place, I hope that the Minister will feel able to support my amendment, which provides that critical third pillar of funding, workforce and waiting time standards to ensure that all those aspirations become a reality.

Baroness Hollins: My Lords, I welcome all the amendments in this group. The importance of parity between mental and physical health is key, and I am grateful to the Minister for confirming that that is the intention behind the Government’s amendments. The explanatory component of the amendment is important, but a question remains over what precisely constitutes mental health spending. I would be grateful if the noble Lord could clarify this. For example, will the report on the expected change and expenditure by NHS England and the ICBs, and the comparison with the previous year, include other aspects of mental health investment not covered by the mental health investment standard, including dementia and learning disabilities? Will the Minister consider identifying in the report whether each ICB has increased the proportion of spending on children and young persons’ mental health, with details of any failure to increase spend?
Turning to Amendment 184, tabled by the noble Baroness, Lady Tyler, to which I also added my name, Dr Adrian James, president of the Royal College of Psychiatrists, said:
“These new standards will help patients get the treatment they need when they need it by setting more rigorous standards and generating vital data, helping to put mental health on a more equal footing with physical health. The standards will only have this impact if matched with similarly ambitious investment and action on the workforce crisis to ensure that no-one has to wait too long for the treatment they need. It’s vital the government provides further clarity on how it will support the implementation of these standards as part of the broader recovery from COVID-19.”
I would add that the range of treatments available in all localities needs to be thought about very carefully by ICBs, just as in surgical teams the right specialist expertise is required for each condition, with reasonable adjustments being made for people who have difficulties in accessing specialist services. I include here, of course, people with learning disabilities. It would be unfortunate if waiting times simply led to an increase in medication clinics, rather than the development of a gold standard treatment in mental health, which would include appropriate skills and psychotherapeutic help alongside appropriate social prescribing.

Lord Davies of Brixton: I want to reiterate a couple of points on this issue that I made at earlier stages of the Bill. I welcome all these amendments, and I am glad about the movement from the Government and that they have recognised the issues raised. Obviously, the key issue here is funding, and a move to better funding for mental health services within the health service is clearly important. It is also important that mental health is referred to in the legislation, and good that the standards have some statutory backing.
I have to express one concern: waiting times and access are important in and of themselves, but they are not a direct reflection of the standard of care. We need to do more work to understand how we can  measure the standard of care being delivered by our mental health services. I have mentioned the issue of the differential mortality. I am sure that there are other issues, but mortality is something that I know a little bit about; those other issues could be brought in so that we directly assess the output as well as the input.
These amendments are important and will address the way in which mental health services suffer because of a lack of esteem. However, they are only treating the symptoms of this lack of esteem. We need to understand a lot more about why mental health, in all sorts of subjective ways, has not achieved a parity of esteem within medical culture as a whole. It is a deep-seated problem which needs to be addressed. The money and standards are important, but we need to understand a lot more about this differential level of esteem and how it can be addressed at its heart—not just by addressing the symptoms.

Baroness Finlay of Llandaff: My Lords, I support these amendments and all that has been said already.
I will put a slight tone of reality on the size of the mountain which has to be climbed to get to the point we want to reach. I do not know how many people last night watched the Channel 4 documentary, “Emergency”, about four trauma centres. It is well worth watching if noble Lords want to see what the NHS is like now under pressure. I happen to know that, on one day last week in one of those major trauma centres, there were seven mental health acute patients in the emergency department but only one mental health nurse was present for all of them. One-to-one care should have been provided. There was nowhere for these patients to go; a further 20 acute patients also needed admission and there were no beds available in the hospital.
This illustrates that the intention behind all this is excellent and laudable—we are finally getting there. However, we have not got to the end of the road; we are just at the beginning. I hope that no one in the public, or in the service, has unrealistic expectations, because it will take a lot of work on everyone’s part to reach the goals we want to reach.

Baroness Walmsley: My Lords, I thank the Minister for listening very carefully to what noble Lords from across the House have been saying about the need to recognise the parity of esteem between physical and mental health, and for giving us some reassurance that the funding for mental health will increase in the future. A lot of mental distress has been caused by the fact that many patients suffering from mental ill health have not been able to reach the threshold for access to services. The reason for that has been a shortage of resources and a properly trained workforce which can deliver the therapies required. At the end of the debate, I hope that the Minister will be able to assure us that those resources will be made available.
My noble friend commented that she hoped that the new standards would not have the unintended consequences of transferring delays from the initial diagnosis to further down the treatment pathway. That  is a very important consideration. We will talk about the importance of increasing the NHS workforce later in our debates. However, will the Minister consider how focusing increased resources on early intervention and prevention will save both money in the end and a lot of distress, as dealing with it early will save patients having to go into more intensive therapies further down the track? It is very important that any increased resources—or, at least, much of them—are focused on early intervention and prevention. I hope the Minister can reassure us of this.

Baroness Merron: My Lords, if the role of your Lordships’ House is to improve the Bill, I feel that this set of amendments will achieve this. I am grateful to the Minister and his officials for responding to the points which were made so powerfully in Committee and in meetings outside this Chamber. The range of amendments will take us further.
The Minister talked about the introduction of transparency and accountability, which are key in the efforts to improve the provision of mental health services. However, of course, improving transparency and accountability is not an end in itself; it is purely a way of getting us to the right place. What will be important is what this delivers. A step along the way to improving mental health services is definitely being made, but there is an awful lot more to do. For example, the Centre for Mental Health estimates that some 10 million additional people, and that includes 1.5 million children and young people, will need mental health care as a result of the pandemic. It would of interest to understand a little more about how the Government intend to make progress on this once the Bill receives Royal Assent. Will we see a recovery plan in the area of mental health services, backed by a long-term workforce plan, something which we will return to later?
On the policy to bring practice into line with aspiration, and on the funding for and redoubling of effort towards achieving parity, while we are talking about this on a national level, it would also be helpful for the Minister to clarify that it applies to all areas of the Bill’s implementation and that the new bodies set up by the Bill will be expected to treat mental health equally from the outset. For example, it would mean ensuring that the decisions about resource allocation, capital spending, waiting times and priorities were all taken on the basis that mental health must be valued equally with physical health.
The noble Baroness, Lady Tyler, was right to point out that we do not start in a neutral position, because we know that waiting times are considerable, standards of services need massively to be improved and the workforce needs to be strengthened in order to deliver those services. It is therefore extremely important that the Minister in putting forward these amendments undertakes to see the job through, so that we do not just have transparency and accountability for their own sake but we deliver for the many millions who will rely on those services.

Lord Kamall: My Lords, I once again thank not only noble Lords who spoke in this debate but those who engaged with us throughout the process. As  the noble Baroness, Lady Merron, said, if the role of this House is to improve the Bill, we have learned much. As a relatively new Health Minister, I have learned so much from the various meetings that I have had with noble Lords, not only on this issue but on many others across the health and care spectrum.
I thank noble Lords who have engaged with me personally but also with my officials to make sure that we closed the gaps as much as we could. I am pleased to hear support from your Lordships for the package of amendments that I have brought forward, and I am grateful.
I stress that this package of amendments should be considered alongside the amendment placing a duty on ICBs to have an appropriate skill mix and experience necessary to deliver all their functions—I hope that noble Lords will look at those in that context—as we expect skills pertaining to the delivery of mental health services to be considered when meeting this duty at the ICB level as well as below that at place level. Many noble Lords have discussed the importance of place.
Amendment 184 would require the Government to report on our plans to improve mental health standards. Access to services is at the heart of the mental health commitments in the NHS long-term plan. The department, NHS England and NHS Improvement regularly report performance against existing waiting time standards in mental health, including improving access to psychological therapies services, children and young people’s eating disorder services and people experiencing a first episode of psychosis.
As noble Lords have acknowledged, last week NHS England and NHS Improvement took another step to strengthen mental health standards, publishing a consultation response following the mental health clinically led review of standards consultation. As noble Lords will know, this sought views on the proposed introduction of new measures, including five new waiting time standards, to support our ambitions to ensure that patients have timely access to community mental health care.
I will now turn to some other points on this and other issues. At this stage, we do not believe that a legislative amendment in this space is needed because of the work under way to move forward on mental health waiting time standards. As I have said, the department, NHS England and NHS Improvement have been looking at this. With the consultation, we hope we will be able to add more.
We acknowledge that no measure is perfect, but the use of first appointments is consistent; they are something that all patients will go through. There are challenges in using measures around ongoing treatment, given that length of treatment varies from case to case, based on different individuals. For example, there might be a good clinical reason for a person to receive periodic support over a number of months or years.
We agree with noble Lords who said that early prevention and intervention are important. For parents and younger children, the Chancellor announced £500 million for early years intervention, which includes £100 million to roll out bespoke parent-infant mental health support. For children and young people, we are  making some progress on rolling out mental health support teams to schools; in fact, we have accelerated rollout to cover about 35% of schools and colleges in England by 2023. We are also introducing new models of care which will give 370,000 adults with serious mental ill health greater choice and control over their care and support them to live well in their communities.
I think a noble Lord asked about spending commitments. The Government are committed via the NHS long-term plan to increase spending on mental health services in real terms by at least £2.3 billion a year by 2023-24. For each year of the current spending review period, spend on mental health will increase as a share of the NHS budget. This is in line with our commitment. We are also ensuring that every CCG and ICB—once they are operational, subject to the Bill—meets the mental health investment standard, so that the spending will increase.
We have also committed to investing £300 million over this spending review to eradicate mental health dormitories by 2024-25. In addition, we are investing £150 million in significant improvements in the mental health estate over the course of the spending review. This will include investing in NHS mental health facilities linked to A&E departments, and enhancing patient safety in mental health units.
The Government will continue to work with NHS England and NHS Improvement on the next steps for the proposed mental health access and waiting time standards. I hope that, with the Secretary of State publishing the reports I have outlined, we will be held to account for this. This will include possible initiatives ahead of any formal performance thresholds being set in future.
I hope noble Lords will agree that, given the amount of comprehensive work already under way and the reports my right honourable friend the Secretary of State has committed to publish, a report such as the one outlined in the amendment is unnecessary. So I beg to move the amendment in my name and hope that the noble Baroness will consider not pressing hers.

Baroness Tyler of Enfield: My Lords, I thank the Minister for that very detailed and comprehensive response to my amendment. While in an ideal world I would like to see an amendment or measure in the Bill on waiting time standards to complement the other work, I accept that there is an awful lot going on that the Government are committed to. I think we will need to monitor very carefully how effective that is, but I will not press my amendment when the time comes.
Amendment 2 agreed.

Amendment 3

Earl Howe: Moved by Earl Howe
3: After Clause 4, insert the following new Clause—“Duties as to reducing inequalitiesIn section 13G of the National Health Service Act 2006 (NHS England’s duties in relation to the reduction of inequalities)—(a) in paragraph (a), for “patients” substitute “persons”;(b) in paragraph (b), after “services” insert “(including the outcomes described in section 13E(3))”.”  Member’s explanatory statementThe amendment extends NHS England’s duty in relation to the reduction of inequalities in access to health services to cover people before they are patients. It also makes it explicit that the duty to have regard to the need to reduce inequalities in outcomes for patients covers outcomes such as the quality of experience undergone by patients.

Earl Howe: My Lords, in moving Amendment 3 I will speak also to the other government amendments in this group, in the name of my noble friend Lord Kamall. Of the many critical topics we discussed in Committee, our debate on health inequalities stands out as one that prompted unanimous and emphatic agreement from all Benches on the need for us to recognise in the Bill the centrality of the inequalities issue. My noble friend Lord Kamall and I took it as our mission to respond to the compelling points raised by noble Lords by bringing forward government amendments on Report, which I now do. These are issues and points of principle about which the Government—not least my noble friend the Minister—feel very strongly.
As the House will know, we think it important to empower local health and care leaders to pursue new and innovative ways to tackle disparities in the most appropriate way for their area. However, we should not miss the opportunity to ensure that this Bill reinforces those intentions in other ways. The amendments are designed to ensure that the Bill fully reflects the strength of the Government’s ambition to address disparities by levelling up every area of the country.
First, we will put beyond doubt that tackling disparities should be an integral factor when making decisions across the NHS. This was something that NHS England’s four purposes for ICSs made clear. The triple aim duty was always intended to support achieving those purposes, and these amendments strengthen the duty on NHS England, NHS trusts and ICBs so that, when decisions are made by NHS bodies, consideration will always be given to the effect of those decisions on disparities. What does that mean? It means that NHS bodies should consider the wider effects of their decisions on the inequalities that exist between the people of England with respect to their health and well-being and the quality of the services that they receive.
We are also going further by strengthening the more specific duties that complement the triple aim. Disparities are not limited just to health outcomes or access; they relate also to the experience of the care that is received. For example, the independent Commission on Race and Ethnic Disparities reported that Asian patients are more likely to report being less satisfied with GP services than their white, black African and black Caribbean counterparts. These amendments seek to strengthen existing duties as to reducing health inequalities on NHS England and ICBs by explicitly including patients’ experience of care, the safety of services and the effectiveness of services to create a more holistic duty that addresses how disparities manifest themselves in health and care.
When it comes to inequalities in access to health services, we can go further. The duties currently focus only on people who are already using or accessing health services. This fails to address those who do not or cannot access health services—and, as we powerfully  heard in Committee, these include many socially excluded and marginalised persons, who are more likely to have preventable health conditions. The point is fully taken, and we have therefore tabled an amendment to ensure that the duties placed on NHS England and integrated care boards as regards reducing health inequalities require the consideration of inequalities in access for “persons”, rather than simply “patients”. The intention here is to improve outreach, as well as access by socially excluded and marginalised groups.
Lastly, we recognise the crucial importance of information on which to base targeted action. The Covid vaccination campaign was unprecedented in the way that it focused activity on every community across the nation, especially where there were disparities in the uptake of the vaccine. Fundamental to that success was the ability to collect and analyse data from across the system so as to target resources in the most effective way.
Our amendment will require NHS England to publish a statement describing certain NHS bodies’ powers to collect, analyse and publish information relating to disparities in health, together with NHS England’s view on how these powers should be exercised. Those bodies will be required annually to review and publish the extent of their compliance with that view. We hope and believe that this will power the evidence-based drive to reduce disparities in health across the country.
I hope that, together, these amendments provide the reassurances that noble Lords sought from their various amendments tabled in Committee. In conjunction, these changes will strengthen the ability and the resolve of the health and care system to take meaningful and impactful action. I commend them to the House and beg to move.

Lord Kakkar: My Lords, in thanking the Minister for having introduced so thoughtfully and elegantly this important suite of government amendments that address the question of inequalities, I would like to pass to the Minister and the Front-Bench team the thanks of my noble friend Lord Patel, who regrettably is unwell, recovering from Covid-19, but who of course spoke with great insight and passion in Committee on this matter, and indeed has engaged actively with the Front-Bench team subsequently in ongoing discussions.
The noble Earl has done something quite remarkable and absolutely essential. There is no need to rehearse the very strong arguments that were made in Committee around the necessity at this particular time to ensure that every element of the National Health Service is able not only to focus its resource and thought quite clearly at the elements of the triple aim but to ensure that, in a tension with those important pan-NHS objectives, the system is never allowed to forget the importance of addressing the inequalities and disparities that regrettably continue to be an abject failure of the delivery of the healthcare system.
Her Majesty’s Government, in proposing these amendments, deal not only with questions of access and outcomes but ensure that data is appropriately collected and all NHS organisations are obliged to pay attention to those data and to act accordingly; that is a very powerful statement and a powerful act of leadership.  But beyond that, in ensuring that the patient’s voice and the public’s voice is heard in these matters, this will set a new tone and new direction for the delivery of healthcare in our country, and Her Majesty’s Government are to be strongly congratulated.

Lord Shipley: My Lords—

Baroness Armstrong of Hill Top: My Lords, I apologise; when there are so many amendments in one group I can never work out just when people who are moving subsequent ones further down the line, as it were, ought to rise.
I will speak to Amendments 63, 65 and 67, and begin with an apology that I was not able to be here to speak to those in Committee. I too had a positive test, although I have to say that I had no symptoms. None the less, I was self-isolating, and therefore was not able to be present in the Chamber.
I welcome the amendments tabled by the Government. I chair the Public Services Committee in this House. In our first report, we looked at public services through the mirror of Covid. We noted and reported, and indeed debated in this Chamber, the significant uncovering or rediscovery of the extent to which inequalities in our society affect people’s health. I am pleased that the Government are responding with some of their own amendments.
My amendments, which are supported by other noble Lords around the Chamber, relate specifically to what I understand the National Health Service calls “inclusion health communities”. For me, these are people living with complex needs in different sorts of communities. I have spent much of my working life involved with such communities and have tried to concentrate on that work in this House. The amendments seek to ensure that the NHS has a much more systematic approach to the health needs of people with complex needs and marginalised communities.
This of course involves people who have been rough sleeping—I know the Minister talked about that in Committee—but it concerns more than just that group. Those who have been rough sleeping do not have access to primary care because they do not have a settled address, but other groups are affected, such as those who have been trafficked, women who are being sexually exploited and the Gypsy, Roma and Traveller communities. The Public Services Select Committee recently held a very short inquiry into Gypsy, Roma and Traveller access to public services, which again exposed a real challenge with health and access to health services. All the data shows, and the stories from these communities tell of, very poor health outcomes, with average life expectancy being 10 to 12 years less than that of the settled community. There are some estimates which put that much higher.
As I said, I welcome the Government’s concern to address health inequalities, but having read very carefully what the Minister said in the earlier debates and in letters, it seems to me quite clear that the Government and the NHS remain behind the curve on this, I am sorry to say. I thank the sector for its briefings, which have been both moving and very useful in painting the picture of just how we are letting these communities  down. As long as we do that, we will have significant inequalities and therefore significant pressures both on and from those communities. They not only end up with poorer health outcomes but are driven to the most expensive end of healthcare. They end up in A&E because they do not know how else to access anything and normally go there far too late in whatever is going wrong with them.
I want to illustrate what I am trying to say with two different stories. I hope this will help the Minister and Members understand where we are coming from. Professor Aidan Halligan was an incredible, innovative leader in the NHS. I got to know him when I was in government and he was working in the Department of Health. He was always interested in what I was doing in tackling rough sleeping, both in the early part of my ministerial career and then when I was Minister for Social Exclusion at the end of it.
Aidan became interested in, among other things, how to get better healthcare for homeless people. He was shocked by what he encountered when he started to look at it. I agreed to chair a meeting in the House of Commons for him to bring together people to address the issue. More than 200 people turned up. That meeting and discussion inspired him to work initially with University College Hospital on developing a responsive survey. He soon set up a charity, which he appropriately called Pathway, which has flourished, to work with the NHS to ensure more responsive healthcare for the homeless. Tragically, Aidan died in 2015, but his legacy of compassionate leadership and response to the homeless lives on. Pathway teams now work throughout the country, although not, unfortunately, in every area or trust area.
The second story comes around Changing Lives, which was known as the Tyneside Cyrenians when I introduced some pilot projects from the Cabinet Office to look at a more holistic service for people with complex needs. The Tyneside group had a new model for outreach work for rough sleepers that employed people with lived experience as outreach workers. They negotiated with the local National Health Service to have a community matron attached to the team so that appropriate referral and treatment could take place.
This was the most successful pilot in the country, and when I left government I kept in contact with it. I went on its board and eventually became chair. We developed the whole organisation and did a lot more work with women. Appropriately, we changed the name to Changing Lives. We developed the principles of working with people with complex needs so that they too were involved, and getting health and other services involved at a more appropriate level than the emergency services. That initial pilot scheme demonstrated to Newcastle how much money it saved, because the “frequent flyers”, as it called them, did not end up in A&E. That is why I say that it has more to recommend it than the very important aspect of making sure that health outcomes are better for people.
Some of the subsequent work we developed through Changing Lives, particularly with those who were exploited sexually, groomed and so on, and those with addictions, has been innovative and transformative. I recommend that the Government look at how they can establish such programmes, but then make sure  that they are normal. That is the problem that these amendments address. There are some really good examples around the country where innovative charities work with the NHS to develop good practice, but by no means is that universal or automatic.
Also, Pathway and Changing Lives include people with lived experience—these days they call them “experts by experience”—in the design and delivery of the service. That makes a huge difference. I know that the Government have said that in general they are in favour of this, but they need to get hold of it to demonstrate that that can be done to a much greater extent.
I understand that the Government and the Minister are concerned about this issue, but the reality is that the Minister sought to reassure the House with measures such as Core20PLUS5. How the NHS keeps coming up with such peculiar and strange hidden titles is beyond me; it is not a phrase I use when I talk to people who have been living on the streets. Anyway, I am told that Core20PLUS5 is one programme that can be used. Then there are JSNAs. They are good and important but not sufficient to get the outcomes we need for both the NHS and the people I am talking about.
I hope that the Government will think again and see how they can systematically ensure that proper attention is paid to how we can enable these communities to access decent services. It is possible—I have tried to be positive and show that—but it must be done throughout the NHS and systematically in partnership with those people who know what it is like to have difficulty in accessing services because they have been excluded for so long. We really must make sure that we make a massive difference on tackling these health inequalities.

Lord Geddes: As gently as I can, I must point out to the noble Baroness that this not the occasion to move her amendments; we will come to that later. She has correctly spoken to her amendments in this group but we will come to them sequentially later.

Lord Shipley: My Lords, now that we are on Report, I must remind the House that I am a vice-president of the Local Government Association.
I rise to speak to Amendments 63, 65 and 67 in this group, to which I am a signatory along with the noble Baroness, Lady Armstrong of Hill Top. I will not repeat the points made in Committee and this afternoon unnecessarily because I am confident that the Government are listening to what has been said and wish to see progress towards levelling up health outcomes and tackling health inequalities. It is the right thing to do.
I lend my support to three policy solutions in particular. The first is the significant opportunity presented by the forthcoming health disparities White Paper. The Government should not miss the opportunity that this presents because it can clearly set out how exactly they propose to lead on tackling the poor health outcomes of inclusion health populations. I hope that the Minister will work closely with the voluntary and inclusion health sectors to shape what the White Paper will say. Secondly, I support the idea of creating a task force from the Department of Health and Social Care and NHS England to help drive forward  the Government’s work to reduce health inequalities for the most marginalised. Thirdly, I urge the Government to take this opportunity to update guidance to specify explicitly that the NHS does not exist in a vacuum and that secure, safe housing is critical to an individual’s health and well-being. I hope that the Minister will be able to confirm that statutory guidance and the White Paper will reflect all these matters.
Having said that, these three amendments—Amendments 63, 65 and 67—are still important. I welcome yesterday’s letter from the Minister, the noble Lord, Lord Kamall, explaining the package of government amendments now also proposed. I am pleased that that letter confirmed the Government’s commitment to tackling health inequalities. It is very positive to see the reference to “persons”, not just “patients”, in Amendment 3 as an important statement of principle both for inclusion health and to improve outreach, as the noble Earl, Lord Howe, said earlier.
Progress has been made following Committee but I still seek reassurance from the Minister that the Government will dedicate the necessary time and resource to tackling the poor health outcomes of inclusion health populations, who can all too easily fall through the gaps in provision.

Baroness Watkins of Tavistock: My Lords, it is a pleasure to speak to this group of amendments. I declare my interest as chair of Look Ahead, a housing association that specialises in working with people with complex needs. I am delighted by the Government’s new amendments in this area—I believe that they go a long way—but I am disappointed that housing appears to have been omitted from the government amendments.
Amendment 65, which adds housing to this section, is one that I would particularly want to support. I want to take a phrase from my noble friend Lord Crisp: health—and here I would add, “including mental health”—is made at home. However, if you do not have a home, you cannot make physical or mental health. Driving in this morning because of the Tube strike, listening to “Woman’s Hour”, which I do not always manage to do, I heard a dramatic example of somebody who has fled domestic abuse and been temporarily rehoused by the council, but has no white goods. She is diabetic, so her insulin is out of control because she cannot keep it cold. What a straightforward example of how housing and simple equipment can facilitate good health.
Another example is where we discharge people to safe accommodation, where they have the opportunity for rehabilitation or to cope with a long-term disability that may have occurred as a result of an accident. This requires sheltered and semi-independent living accommodation to be built. If those issues are carefully considered by our new boards, together with housing locally, we will find a way forward, to reduce the distress of significant illness and domestic violence, to enable young people in family breakdown to move to bedsits rather than to the streets, and to make care leavers feel safe—as well as older people then knowing that there is somewhere that they can move to. We know that those with significant incomes are increasingly  moving, because they can fund themselves, to sheltered accommodation, which reduces loneliness and gives all sorts of advantages in later life.
I again thank the Government and remind them that, tragically, the average age of death of people experiencing homelessness remains at 46 years for a man and 43 years for a woman.

Baroness Morgan of Drefelin: My Lords, I do not want to detain the House for too long, as there is an awful lot of business to think about on Report. However, as I put my name to Amendments 63, 65 and 67, tabled by the noble Baroness, I want to press the Minister on the question of data.
I am advised, as I am sure others are, by really experienced charities, which say that one of the real challenges here, which will be a challenge for the ICSs when they are trying to do a great job in terms of compliance on disparities, is that the data on inclusion health populations is very incomplete. While there have been efforts to collect data on housing status, for example, that has been relatively incomplete and unsuccessful. So what I want to hear from the Minister is how we can be sure that through the development of this commitment to tackling health inequalities with an evidence-based approach, populations such as the inclusion health population are not invisible because the data is so difficult to collect. Is this something that the forthcoming White Paper could pick up? Will it focus on how the health system leaders will get the tools that they need to do a really great job for these populations, who have such complex needs and who really draw on the health service, A&E, et cetera, in a very intense way? There is such potential to make real progress, whether it is in the interests of people coming out of care, sex workers who are really challenged, or homeless people. We are all only a few steps away from that, are we not? So I would be interested to hear from the Minister whether that drive to collect comprehensive data to inform this work can be channelled in some way through a forthcoming policy initiative.

Baroness Walmsley: My Lords, from these Benches I thank the Minister and the whole Front-Bench team for the way they have engaged with the House on the issue of doing something really serious about addressing health inequalities.
Many of us put down amendments in Committee: dealing with inequalities was dotted all over the Bill. We even suggested that perhaps we needed a quadruple aim—an additional aim. The Government have taken a different but none the less effective approach, and I really welcome the fact that dealing with health inequalities has been made integral to the first two aims of the triple aim.
The Government have done two things that I particularly welcome. The noble Lord, Lord Kakkar, mentioned the engagement of the noble Lord, Lord Patel, with the Bill team on making sure that data can be collected. Without collecting the data, you cannot analyse or take action on addressing health inequalities.
The second thing, which the Minister mentioned in his introduction, is government Amendment 21, which is about the experience of people in the health service. He mentioned that the experience of people from an  Asian background can sometimes be poor. I can give him an example of where that has been the case. My daughter has a friend, an Asian gentleman, who had a very painful physical injury. Very unusually, although his physical problems have now healed, he has been left with a mental scar because of his experience with the health service. This is very unusual, but he was not treated with compassion or respect. Indeed, it was more like discrimination—so I really welcomed what the Minister said about the importance of the experience of people from all demographics and ethnic backgrounds in the health service. It is vital.
I turn to the amendments from the noble Baroness, Lady Armstrong. Like all noble Lords, I have been watching the television recently, looking at the pain that the poor people of Ukraine are going through and seeing children, mothers and whole families huddled in cold, damp cellars. Some of them are taking several days to drive to the border to go to a country that will welcome them, perhaps with even more open arms than we do. It occurred to me that those people, when all this is over—and let us hope it will be over very soon—will probably be suffering from mental and physical illness. It also then occurred to me that there are people in this country who have poor-quality housing, insecure housing or no housing at all. When you put those things together, it is not surprising to realise that such people will be suffering from more serious and more frequent physical and mental ill-health than the rest of us who are in good-quality, secure housing. So the noble Baroness has hit on some very important issues about health inclusion communities and about the importance of housing to making health, and we support what she has to say.
I end by sincerely thanking all three Ministers and the Bill team for the way they have addressed this issue of health inequalities, and I really look forward to it making a real difference in future.

Baroness Thornton: My Lords, the noble Baroness, Lady Walmsley, expressed that very well indeed. From these Benches, I say how much we welcome these amendments and thank the Minister for introducing them. I also join the noble Lord, Lord Kakkar, in regretting the fact that our friend Naren Patel—the noble Lord, Lord Patel—is not with us today. His speech on this in Committee was outstanding, as his speeches always are. In fact, the whole debate was the House at its very best in expressing its view.
We welcome these amendments, and I was very pleased to add my name to Amendment 3 on behalf of these Benches. I was not as energetic as the noble Lord, Lord Kakkar, who put his name to all of them, but that was a symbol of the fact that we supported all these amendments.
We support them because, as people have mentioned, they recognise the importance of addressing inequalities from the top to the bottom of the National Health Service, and of monitoring, counting and research—not a tick-box exercise to say that you are tackling inequalities. As I have mentioned before, I am a non-executive member of a hospital in London. In fact, I have just completed three days of its workforce race equality training. That was three days out of my life during the course of this Bill, but it was definitely worth while.  It absolutely was not always comfortable, and nor should it have been. It did indeed raise issues, many of which were raised in research published on 14 February by the NHS Race & Health Observatory. It basically says that the NHS has a very large mountain to climb in tackling race inequalities and inequalities across the board. It is a worthwhile report, which I am sure the noble Earl will be paying attention to in due course.
I also want to say how much I support my noble friend in bringing forward her amendments on the homeless. Coming from Bradford, I am particularly fond of a GP surgery called Bevan Healthcare, named after the founder of the National Health Service. It was started by my local doctor in Bradford, who spent his spare time providing GP services on the street to the homeless. From that, the NHS was commissioned to provide a GP surgery specifically directed to the needs of people who are itinerant and homeless, working girls and so on. It is still there, and it is a brilliant example of how to deliver the service, and of the money it saves the NHS at the end of the day. As I think my noble friend Lady Armstrong said, if you get this right then people do not end up in emergency care or worse.
We hope that the Minister will respond positively to these amendments. I thank him, his team and the Bill team, who addressed this issue thoroughly and with a great deal of success.

Earl Howe: My Lords, this has been a very fruitful discussion and I am most grateful to all noble Lords who have spoken. I especially thank my noble friend Lord Young of Cookham, the noble Baronesses, Lady Walmsley, Lady Thornton and Lady Hollins, the noble Lord, Lord Kakkar, and the noble Lord, Lord Patel, in his absence, the King’s Fund and the Health Foundation for their contributions, both inside and outside this Chamber, in shaping this debate and the amendments before us.
Without wishing to repeat what I said earlier, I commend the government amendments to the House as they will strengthen the ability and resolve of the health and care system to take meaningful action on tackling health disparities. I next thank the noble Baronesses, Lady Armstrong of Hill Top and Lady Morgan of Drefelin, and the noble Lord, Lord Shipley, for tabling their three amendments and for the focus they bring to the issues of housing and homelessness. I found the account of the experience in government of the noble Baroness, Lady Armstrong, and the work of Professor Aidan Halligan, whom I too remember with great respect, compelling. I agreed with so much of what she said.
Let me say straight away that the Government are committed to improving the health outcomes of inclusion health groups, as they are known. That is precisely why we tabled the amendment to expand the inequalities duty placed on NHS England and ICBs beyond simply patients to incorporate people who struggle to access health services such as inclusion health groups, but there is much more to say on this.
We have been clear throughout our engagement on integrated care partnerships that housing and homelessness services are essential in improving poor health for  many. As my noble friend mentioned in Committee, the Bill already provides that ICPs may include the integration of those services in their integrated care strategy. We will continue to encourage the inclusion of housing and consideration of inclusion health groups in our guidance for ICPs. I hope that that is reassuring and will convince noble Lords that Amendment 65 is unnecessary.
I was very interested to hear what the noble Baroness, Lady Thornton, had to say about Bevan Healthcare. My noble friend Lord Kamall tells me that he has been a long-term supporter of a charity called Vision Care for Homeless People. It is not surprising that, with my noble friend in the Department of Health and Social Care, he and the department have been driving forward a wider agenda aimed at improving the lot of homeless people.
The noble Lord, Lord Shipley, referred to the health disparities White Paper which we will be publishing later this year. That will take a broad look at the factors that affect people’s health and will focus on the people and places facing the worst health outcomes. It will mean looking at the biggest preventable killers, such as tobacco and obesity, as well as the wider causes of ill health and access to the services needed to diagnose and treat it in a timely and accessible way. It is important to emphasise that that endeavour will not be confined to the Department of Health and Social Care; it will be a cross-system endeavour, relying on close working among the NHS, wider health and care services and across central and local government.
It is also important to mention the Levelling Up White Paper. The Government’s focus on preventing homelessness will be renewed by working across government and with local partners to tackle the root causes of homelessness, in order to make sure that the flagship rough sleeping initiative continues to provide support tailored to local areas.
The pandemic highlighted in further stark contrast the importance of integrated care and the need for key services to work closely together to support those experiencing homelessness. Integrated care partnerships will bring together the NHS, local authorities and the voluntary sector, and it will be their job to develop strategies to address the public health and social care needs of people living in their areas, including people experiencing homelessness.
Legislating for new structures is one thing, but what are the Government actually doing to improve health outcomes for people experiencing homelessness or rough sleeping? Work is going on as we speak. We recently announced in the spending review £640 million, to be spent by 2024-25, to tackle homelessness and rough sleeping. This fund will build on progress already made in this area, including support for substance misuse through the rough sleeping initiative. Through the NHS long-term plan, the NHS has committed £30 million for specialist mental health services for people sleeping rough—that is £10 million a year by 2023-24. This year, we are delivering £52 million for substance misuse treatment services for people sleeping rough, and that will fund evidence-based treatment and wraparound support, including for those with co-occurring mental health needs.
The noble Baroness, Lady Morgan of Drefelin, aptly referred to the need for comprehensive and accurate data. I quite agreed with everything she said. We initially looked very carefully at whether there was a statutory basis on which to issue guidance in this area and, in the end, we concluded that there was not. But the amendment that we have proposed requires practical steps which we believe will achieve similar policy aims.
In practice, NHS England must produce a document that sets out NHS bodies’ powers in relation to health inequalities information, together with its view of how those powers should be exercised, as I mentioned earlier. That is bolstered by a requirement for those bodies, in their annual reports, to review the extent to which they have complied with NHS England’s view. In our opinion that essentially squares the circle of the need for this crucial area not to fall between the gaps. I will of course supply the noble Baroness with any further information that I can on how those plans look like they are shaping up.
Finally, defining inclusion health groups in law is very difficult. We have therefore committed to putting a more in-depth explanation of the term in guidance, as well as advice on identifying these groups and their health needs. We recognise that the populations most at risk from health disparities may vary between localities and may change over time; that is an obvious truth. By not defining the term in legislation, we allow bodies to react to their own local and system population’s needs, as seems appropriate to them. We feel that statutory guidance is a better vehicle for helping to set out how health and care services can better identify and address the needs of these groups when drawing up the integrated care strategy.
I ask the noble Baroness, Lady Armstrong, not to move her amendments when they are reached and I beg to move Amendment 3.
Amendment 3 agreed.

Amendment 4

Lord Kamall: Moved by Lord Kamall
4: After Clause 4, insert the following new Clause—“Duties in respect of research: business plan and annual report etc(1) The National Health Service Act 2006 is amended as follows.(2) In section 13L (duty in respect of research), after “functions,” insert “facilitate or otherwise”.(3) In section 13T (business plan), in subsection (2)(a), after “13G” insert “, 13L”.(4) In section 13U (annual report), in subsection (2)(c) (as amended by section 69(4) of this Act), at the appropriate place insert—“section 13L;”.”Member’s explanatory statementThis Clause provides that NHS England’s duty to promote research etc includes doing so by facilitating research. NHS England is also required to explain in its business plan and annual report how it proposes to discharge or has discharged its duty to facilitate or otherwise promote research etc.

Lord Kamall: My Lords, in moving Amendments 4, I shall also speak to Amendments 23, 58 and 79 in my name. Before I start, I really should acknowledge the  contribution and engagement of a few noble Lords, in particular the noble Lords, Lord Sharkey and Lord Patel, and my noble friends Lady McIntosh and Lady Blackwood for their constructive engagement with me and my officials.
We have seen the power of research as we have made our way through the pandemic, and research will continue to be essential. I agree that research needs to be embedded in the very DNA of the NHS. Earlier this week, I chaired a round table with a number of research charities and other stakeholders, and we all talked about the importance of embedding research into the NHS. A bit like the challenge I had when I was in academia, when you wanted more time for research but at the same time were told to get on with your day job of teaching students, likewise many clinicians are under the same pressures in terms of the day-to-day delivery of healthcare while wanting time for research.
We know that informed research helps to improve healthcare and health outcomes. It brings benefits to patients, staff, the NHS and the wider economy. We believe that integrated care boards will play a leading role facilitating and enabling research and fostering a culture and environment for research to flourish. To this end, the Bill currently places a duty on each ICB that it
“must, in the exercise of its functions, promote … research on matters relevant to the health service, and … the use in the health service of evidence obtained from research.”
I have, however, heard clearly from noble Lords that they want to see a step change in research. That is a request, or a plea, that I agree with, so rather than directly funding or conducting research, ICBs will primarily facilitate and enable it. However, ICBs will also have the power to conduct, commission or assist the conduct of research. This could include hosting or being a collaborating partner in research infrastructure.
I also heard from noble Lords, particularly the noble Lord, Lord Sharkey, that it is not clear what a duty to promote research should involve. To that end, I have tabled Amendments 4, 23 and 79 to clarify that the meaning of “promote” includes “facilitate”. I once again thank the noble Lord, Lord Sharkey, for his engagement. This highlights that facilitation is a subset of the range of activities meant by promoting research while retaining the breadth of a duty to promote research.
The duty is broad and could be met in a number of ways. For example, when exercising its commissioning functions, an ICB may select providers which have a proven track record of being research-active or can demonstrate the intention and capability to participate in research. The provision is also flexible so that bodies can develop the processes and structures that work most effectively, but we anticipate that ICBs would have dedicated research offices or teams to support their role in research and to encourage the conduct of research.
To ensure that research is fully embedded in local systems, we expect ICBs to consider research when preparing, with the responsible local authority, a joint strategic needs assessment articulating local research needs where they identify them. We would also expect ICBs to ensure that the joint local health and well-being  strategy sets out how research needs can be met by the ICB. We have tabled Amendment 35, which is to be debated in the next group, to ensure that the research duty, along with other duties, is given particular consideration during ICBs’ planning of their strategies. We have also tabled a package of amendments to provide increased transparency, accountability and oversight of the research duties.
During the debate in Committee, my noble friend Lady Harding remarked that
“what gets measured gets done”.—[Official Report, 24/1/22; col. 47.]
We agree. Amendment 4 requires NHS England’s business plan to explain how it proposes to discharge its research duty and requires its annual report to contain an assessment of how effectively it discharged this duty. We have tabled similar amendments for ICBs. Amendment 55, also to be debated in the next group, would require that ICB annual reports must explain how the ICB has discharged its research duty. Amendment 58 would require that the NHS England’s performance assessment of each ICB includes an assessment of how well it discharged its research duty. I beg to move.

Baroness McIntosh of Pickering: My Lords, I take this opportunity to thank my noble friend for listening and acting in the terms set out in the amendments in this group, which I support on research as far as they go. I have to express my disappointment that my noble friend has not seen fit to extend his bonhomie to NICE. I have therefore tabled Amendment 29, and I am delighted to have the support of the noble Lords, Lord Hunt of Kings Heath and Lord Patel. As set out by the noble Lord, Lord Kakkar, our thoughts are with the noble Lord, Lord Patel, who is unable to be with us today, and we wish him the speediest possible recovery. It is a great shame that he cannot be here today because we would all wish to pay tribute to his work historically as the forerunner of NICE. We are grateful to him for it. It is a great disappointment to me that he is not able to be here in person.
I also support Amendments 171 and 178 in the name of the noble Lord, Lord Hunt, but I shall leave the noble Lord to set them out.
My noble friend has set out that the government amendments set a responsibility on integrated care boards to respond annually and to measure the research work that they have done. Quite frankly, I am a little concerned and gobsmacked as to why my noble friend is not insisting that integrated care boards do the same as regards NICE. The key provision of my Amendment 29 is:
“Within 28 days of any medicine or device receiving market authorisation from NICE, an integrated care board must update its formulary to include that medicine or device.”
I have set out other provisions, but the other one to which I draw attention is in proposed new subsection (3), which says that every year an individual ICB must report
“in a publicly accessible format”—
to me that would mean it being accessible on its website—
“all medicines and devices that have been added and removed from their formulary over the previous year and maintain an active list of all medicines and devices available on their formulary.”
I would like to get away from what is an effective postcode lottery, meaning that where you live determines the medicine or device from which you can benefit. In this day and age, in the 21st century, it is unacceptable that, for all the good work that NICE does, we are still living in that capacity, whereby not everyone will be able to benefit, as pharmacists, physicians or patients, from the advice that NICE has given.
I am delighted to say that I am supported in this by a number of bodies, including the JDRF, which makes particular reference to the importance of NICE’s work on type 1 diabetes—and we know how invasive and extensive type 1 diabetes is. I pay tribute to our right honourable friend, the former Prime Minister Theresa May, who went public with the fact that she was a type 1 diabetes sufferer. For a woman in that position to go public about her condition captured the public imagination and made it more acceptable to say that people suffer from type 1 diabetes. EMIG, the ethical medicines association, also supports this provision, as does Vertex Pharmaceuticals.
I have only recently become aware of a project called the Orbis scheme, which aims to deliver faster regulatory approval of innovative cancer treatments. I think that all noble Lords would wish to support the speediest possible diagnosis and delivery of treatment that is in play through this project and scheme.
I end with a plea to my noble friend that the Government, MHRA, NICE and NHSE all work closely together, not just among themselves but with the industry and with all patient organisations and clinicians, to make swifter regulatory approval a reality, in keeping with the ambitious government life sciences vision, which I support.

Lord Hunt of Kings Heath: My Lords, as this is my first contribution on Report, I declare my interests as a member of the GMC board and president of GS1, the British Fluoridation Society, the HCA and HCSA.
I welcome what the Minister said about research and its importance, and some of the tensions between practical work as a clinician and the crucial importance of clinicians engaged in research. The amendments that he introduced are very welcome, but like the noble Baroness, Lady McIntosh, I am disappointed that he has not brought similar amendments forward in relation to NICE. One suspects that it is something to do with money; he thinks that giving away amendments on research is cost-free, whereas there might be a resource implication when it comes to NICE. That is a pity.
The noble Baroness has talked about a postcode lottery in this country on the outcome of NICE judgments, but we also have a European postcode lottery. The fact is that NHS patients have much less access to modern new medicines and devices than those in many other countries. Stats that I have seen on medicines suggest that, for every hundred European patients who can access new medicines in the first year they are available, just 15 UK patients have the same access. We know that even when NICE has given its blessing to new medicines and treatments, take-up in the NHS still lags behind that in other countries.
I think that the noble Baroness, Lady McIntosh, and I were somewhat puzzled by the ministerial response in Committee in this area. We know that the NHS uses all sorts of rationing devices to prevent those new medicines and devices being allocated generally throughout the NHS, notwithstanding what NICE has to say—that is why I support the noble Baroness’s amendments. Essentially, my two amendments seek to build on the principles that she has referred to.
Amendment 171 relates to three issues which I think remain from Committee. The first relates to the links between licensing and reimbursement processes. Happily, the MHRA has established two new licensing pathways, ILAP— the Innovative Licensing and Access Pathway—and Project Orbis, for cancer medicines. This is very welcome; it is designed to speed up access.
However, the challenge with faster licensing decisions is that NHS reimbursement decisions need to speed up too, otherwise medicines can be placed on the market but cannot be made available to patients on the NHS. To its credit, the MHRA has designed this into ILAP, because NICE is directly involved in ILAP, and licensing and reimbursement decisions can be joined up. However, in respect of Project Orbis, there has been no such effort. Late last year, breast cancer patients faced the worrying situation where a drug, Trodelvy, which offered them hope, was licensed through Orbis but was not then available on the NHS. My amendment would therefore ensure that NICE acted to issue guidance on Project Orbis medicines as close to licensing as possible, as it does for ILAP.
Secondly, the amendment would clarify that NICE alone is responsible for determining its methods, as an independent body should be. In its recent methods and processes review, it concluded that
“there is an evidence-based case for changing the reference-case discount rate to 1.5% for costs and health effects. However, because of the wider policy and fiscal implications and interdependencies that are beyond the reach of this review, no change to the reference-case discount rate”
could be made. It further stated:
“Reducing the discount rate will make most technologies appear to be more cost effective.”
We are therefore in a situation where NICE wants to make a change to its methods, which would result in more medicines being made available to patients but is being stopped from doing so. That is not acceptable. NICE should be free to determine its methods, including the discount rate.
The final effect of the amendment would be to clarify the role that the current voluntary scheme, VPAS, and the statutory scheme play in reimbursement decisions. These schemes essentially cap the NHS’s expenditure on drugs, meaning the exposure of the taxpayer to spending on drugs is limited. The problem is that the health service then adds a whole host of other mechanisms to restrict access to medicines as well. My own view is that once we have VPAS and the statutory scheme in place, we do not need those other mechanisms.
Amendment 178 builds on this. I have already referred to the Project Orbis scheme. It has great potential, but unfortunately, as Gilead has pointed out, there is a lack of alignment across the system between government, the MHRA, NICE and NHS  England, which has an impact on timelines for approval. This is particularly concerning in light of moves by other countries such as France to legislate to enable early access to innovative therapies prior to a cost-effectiveness assessment, with any difference in the final agreed price rebated by the company. We need an integrated access and funding pathway for medicines licensed by Orbis, prior to NICE approval, modelled on the French system, whereby companies rebate any difference in price following the decision by NICE.
The final point I will make is that we also need to deal with NICE capacity issues. In January 2022, NICE highlighted in its board papers that approximately 20 evaluations were paused in 2021-22 due to capacity constraints because of vacancies. This is despite increased industry fees paid for health technology assessments. While NICE’s vacancy rate has reduced, the same board papers note that:
“Organisational capacity continues to be the key risk for NICE ... strategy, and gaps in hard to fill specialist roles in a competitive global market.”
I would like the Minister to respond to this.
More generally, I hope that the Minister can give us some assurance that he and other Ministers recognise that all these initiatives to speed up access, excellent though they are, will come to very little unless they can sort out the NHS side of things and get rid of some of these rationing mechanisms which have been put in place.

Lord Sharkey: My Lords, like the noble Lords, Lord Patel and Lord Kakkar, I have added my name to the government amendments in this group. These amendments directly address the criticisms which we made in Committee that, as things stood, a duty to promote research lacked any real force. Since we made these criticisms, we have met with the Minister and his officials to try to strengthen this research duty and make it more meaningful and concrete. These amendments, and the others in the next group, are the result of our discussions.
The Minister has explained, and given some examples, how they would help. The importance lies on what new things the amendments put in place. They require the NHS to explain, in its business plans and annual report, how it proposes to discharge, or has discharged, its research obligations. They also require a performance assessment of ICBs, which includes how well they have discharged their research duty and their duty to facilitate and promote the use of evidence in research. I thank the Minister and his team for their extensive engagement on the question of research in the NHS. I am pleased that we have strengthened the research duties of the Secretary of State and the ICBs. I am particularly pleased that progress will now be formally reported and assessed.
I should also mention that, in his letter of yesterday, the Minister listed a number of non-legislative measures either being taken or developed for facilitating or fostering a culture of research within the NHS, and for holding to account the people responsible for delivering this.
Finally, the noble Lord, Lord Patel, has asked me to say how sorry he is that he cannot be here today. He wanted the House to know that he supports the  Government’s research amendments and is grateful for their co-operation in generating more research in the NHS. As the noble Lord, Lord Kakkar, has said, he is at home recovering from Covid, and I am sure that the House wishes him a speedy recovery.

Lord Kakkar: My Lords, I remind noble Lords of my own declarations of interests made in Committee: I am chairman of the Office for Strategic Coordination of Health Research, chairman of the King’s Fund and chairman of King’s Health Partners. In so doing, I make particular reference to the King’s Fund, since the Minister, in closing the last group of amendments, indicated the contribution to discussion which the fund has made with regard to the questions of inequalities.
I strongly support the amendments on the question of research that have been put by Her Majesty’s Government, and so ably and thoughtfully presented and introduced to your Lordships’ House by the Minister. The noble Lord, Lord Sharkey, has summarised why this is so very important. Ultimately, a research culture needs to be promoted at the heart of the NHS, and these amendments go a long way to achieving that clear objective.
There is so much by way of other initiatives that Her Majesty’s Government promote on the funding of research and support to bring together different parties to drive the broader life sciences agenda. However, ultimately, this all depends upon an NHS which is strongly supportive of, and facilitated to deliver, that research. Without this commitment, there was a very real risk that, with the other priorities that the NHS is inevitably required to pay attention to, the need to promote and facilitate research would be lost.
In facilitating research, NHS organisations, the Secretary of State, the NHS board and integrated care boards will have to pay attention to not only the facilities provided but the attendant workforce questions, ensuring that a workforce is properly prepared and able to engage in the research agenda, that progress in that regard is properly reported and that the full benefits of a research culture and the output of research are available to patients throughout our country.

Lord Warner: My Lords, very briefly, I support Amendments 171 and 178 in this group, spoken to so ably by the noble Baroness, Lady McIntosh, and the noble Lord, Lord Hunt. I do so as a former pharmaceuticals Minister and a former NICE Minister. The rather boring thing about all this is that the postcode lottery issue was alive and well when I stopped being a Minister, 15 years ago. It has continued to flourish throughout that time. The noble Lord, Lord Hunt, does not exaggerate in any way how the NHS is quite creative at finding ways around implementing speedily some of the drugs and medicines recommended by NICE.
For a long time, part of the problem has been—Amendment 178 starts to make a move in the direction that I think has been lacking—that we simply do not monitor enough what has happened to NICE recommendations and the take-up of new medicines. It is not really built into the regulatory system. If we  are serious about inequalities—I have listened to many of the debates on inequalities today and previously—and levelling up, access to new medicines is pretty important. I have a terrible suspicion that, if we looked around very carefully, we would find that the same parts of the country, year in and year out, are not taking up the medicines as speedily as others. The reason I say this is that we know from the regulator’s evidence that the financial and clinical underperformers are, much of the time, the same places, year after year. I suspect that these are many of the places we need to look at if we want to tackle the postcode lottery of NICE recommendations.

Lord Lansley: My Lords, I join the debate briefly to add my thanks to the Government for the amendments on research that they have brought forward in this group. It is extremely helpful, as the noble Lord, Lord Kakkar, said, to entrench the concept of a research culture inside the NHS. In our various ways and guises, we have all encountered some of the difficulties of diffusing innovation and the take-up of new medicines in the NHS.
The point was made very well by the noble Lord, Lord Hunt of Kings Heath, but he did not say why the NHS does not adopt new medicines as rapidly as some other European systems have. I do not think we have more conservative clinicians than other countries, but we do not have a third-party payments system. We do not have a system whereby the patient can ask “What about this?”—these days, increasingly, they do—and the clinician can say yes, and pass the bill to somebody else. Instead, our system centrally determines the extent to which new medicines will be available. We have a particular requirement in the National Health Service for a system which looks for areas where there is value in innovation, disseminates it, takes it up and makes it available to patients.
I make two other points. One is to say thank you, as I am not sure I will get another opportunity to do so. We had substantive discussions about rare diseases; the noble Lord, Lord Sharkey, in particular spoke very well and fully about the needs involved, and the Government published their England Rare Diseases Action Plan yesterday. On orphan drugs, that will give significant additional impetus to the availability of treatments for those with rare diseases. I very much welcome that.
Secondly, Amendment 178 in particular is interesting. I do not necessarily advocate that we adopt it, but it asks the Government do something that they generally have not done and ought to do, which is to come back to the issue of access to medicines and treatments—and, I would add, to medical devices—and ask how well we are doing at the process of bringing that into effect and how well our Accelerated Access Collaborative, which is supposed to look at all these things and make them work together, is making that happen.
The beauty of Amendment 178, on which I will add just a little, is that we ought to have a very clear timetable for how we move the system forward. I hope the Government will adopt this. In January 2024, we will have the next voluntary pharmaceutical pricing and access scheme. The industry will be looking, rightly, to arrive at a position where all the initiatives mentioned  give patients access to medicines in this country as soon as in any other healthcare system. On that basis, the industry will be prepared to understand that not just the NHS but the Government will look to get some pretty cost-effective prices out of it.
Now I do not happen to think that it is NICE’s job to make that relationship happen. I happen to think that NHS England is increasingly equipped to be a central player in this process. It should sit alongside NICE when it carries out health technology assessments in what is effectively a trialogue with the industry and say, “Well, how can we ensure that the patient has access to this medicine, and at what price? Can NICE act as the referee to establish whether the price and the incremental benefit are reconciled to be cost effective for the NHS?”
We should build that into the system over the next 18 months so that, when we start the new scheme in January 2024, the system is understood to work. It should not depend on large-scale transfers of money, with overpriced new branded medicines on the one hand being recycled back to the NHS to go into the innovative medicines fund on the other. This tracking of money around the system is not the best way to make it happen. We should aim for the industry to be paid what the health technology assessments and the NHS budget requirements mean is a fair price for the medicines it is providing—and that is what the industry should expect.
Everybody should be working to arrive at a position where, when a medicine obtains authorisation—in other words, when it is deemed safe, clinically effective and of good quality—and a clinician recommends it for a patient, the patient should have access to that medicine through the NHS. That is what we are aiming for. It has not always been true, but it ought to be in the future. We need a system that people, including clinicians in the NHS, understand and that supports their ability to prescribe medicines in that way.

Baroness Thornton: My Lords, I do not intend to speak about this for very long, because I feel that I am the least well-equipped person in the whole Chamber to do so—possibly with the exception of the Minister, which is often the way and is how I felt when I was a Minister; I would stand up to speak about research and other huge subjects and everybody else in the Chamber who had spoken certainly knew a lot more than I did, and that is the case here.
Noble Lords may recall that the starting point at Second Reading and in Committee was that there was no place for research in the Bill at all—so I congratulate noble Lords who picked this up and ran with it, and, indeed, the Minister and the Bill team on taking it on board and producing these amendments. That is helpful; as the noble Lord, Lord Kakkar, said, it is about the future and it is exactly the right thing to do.
I also agree with the noble Baroness, Lady McIntosh, and my noble friend Lord Hunt in their disappointment on the issue of NICE. They are quite right about the access and availability of medicine and devices to healthcare practitioners and that the system is still uneven; also, of course, nobody is asking how we are doing and whether it is working. It is a shame that  these aspects have not been included in the Bill, but I suspect that the noble Baroness and my noble friend will probably live to fight another day.

Lord Kamall: My Lords, I am grateful to all noble Lords who have spoken thus far in this debate. I also thank the noble Baroness, Lady Thornton, for expressing her confidence in my ability to understand these issues; I fear that she may be right.
Turning first to Amendment 29, it is firstly important to note that it is the MHRA, not NICE, that licenses these medicines in the UK. NICE makes recommendations on whether the price that the NHS pays for treatments represents value for money. Access to effective new treatments for NHS patients is a priority for the Government. That is why we have committed to maintain the funding requirement for NICE appraisal of recommended treatments.
The standard contract also stipulates that providers must ensure that formularies include all NICE appraisal-recommended treatments. NICE’s guidance on developing and updating local formularies also clearly states:
“When a NICE technology appraisal recommends a medicine, adopt the medicine into the local formulary automatically, if clinically appropriate and relevant to the services provided by the organisation. This process should take place within 3 months.”
I believe that this represents a robust legal framework for ensuring compliance with NICE’s appraisal decisions. A stronger legislative requirement to include all NICE-recommended treatments on formularies within 28 days of a NICE decision would remove any flexibility both to vary the timescale where there are barriers to implementation, or where a product was not relevant to a particular organisation.
Turning to Amendment 171, NICE rightly operates independently from the Government, and key to this is setting its own procedures for developing guidance and recommendations. This includes setting its own discount rate, taking into account the wider policy and fiscal implications. NICE recently carried out a comprehensive review of its methods and processes for making appraisal recommendations, and the changes that NICE is introducing will ensure that its processes are fairer, faster and more consistent. I assure noble Lords that NICE already aims, wherever possible, to make timely recommendations on new medicines with draft guidance around the time of licensing, and final guidance within three months of licensing. However, NICE’s ability to issue guidance depends on an evidence submission from the manufacturer. It would not therefore be appropriate to place a requirement in legislation for a specified timeframe when that is dependent on other organisations.
This amendment would also require NICE to take account of a company’s membership of the Voluntary Scheme for Branded Medicines Pricing and Access, or the statutory scheme, in making its recommendations on medicines. These schemes have a very different purpose from NICE appraisals, which ensure that new medicines are clinically and cost effective, and they are time-limited, so would create significant disparities between medicines launched at different times.
I turn now to Amendment 178. I hope I can assure the noble Lord that arrangements are already in place to regularly review and monitor delivery against priorities  and objectives, including through accountability meetings, engagement with external partners and public board meetings. The Government believe that regular monitoring through existing arrangements is the right approach and do not consider that a requirement to carry out a review is necessary. I assure the noble Lord that the changes recently introduced by NICE will make its methods and processes fairer, faster and more consistent, will ensure that they are suited to new and emerging types of technology, and will provide more equitable access for those with severe diseases. The vast majority of cancer medicines covered by the previous end of life flexibilities would also be covered by the severity modifier.
Placing requirements on NICE through primary legislation to use specified processes would fetter its independence to determine its own methods and processes, and it would be unfair to operate two different approaches at the same time. The amendment proposed by the noble Lord could also impact negatively on cancer medicines that were not eligible for the end-of-life flexibilities in their first appraisal but may be eligible for the severity modifier.
I will now turn to a couple of specific questions, one of which was about the uptake of medicines in the UK. The NHS is legally required to fund NICE-recommended treatments, normally within three months, and this requirement will apply to ICBs once established. Differences in healthcare systems between different countries—in commissioning, disease prevalence and population demographics—make any direct comparison of uptake difficult, and the speed at which innovation is taken up is not the only effective measure of quality of care.
However, we are committed to making the UK one of the most pro-innovation healthcare systems in the world, and we have made some real progress in recent years. Noble Lords have mentioned the Accelerated Access Collaborative, which was established to support the appropriate uptake of NICE-recommended medicines and devices, as my noble friend Lord Lansley said. In 2019-20 alone, the AAC helped more than 2,500 innovators to develop their cutting-edge products and launch them in the NHS. Nearly 750,000 patients have benefited from access to these products, and they spent around 125,000 fewer days in hospital as a result.
I should add that NICE is the independent body responsible for methods and processes. NICE’s consultation stated that there is an evidence-based case for changing the discount rate to 1.5%, but it acknowledged the wider policy and fiscal implications and proposed to maintain the existing reference case discount rate while further data is collected on the likely effects of a change to the discount rate. NICE’s changes are in line with the department’s expectations for the review as set out in the VPAS agreed with industry. It is important to recognise that any changes to NICE’s methods could have financial impacts beyond the duration of the current VPAS.
On the postcode lottery, we have reporting tools at our disposal to monitor the use of innovative medicines and products. NHS Digital publishes a biannual report  on the use of innovative medicines by the NHS in England, known as the innovation scorecard. The latest publication, from June 2021, shows that uptake of more than 70% of NICE-approved medicines reported in the scorecard has increased over the past 12 months. We are committed to further strengthening these innovation metrics and to improving our understanding of the use of innovative medicines and medicinal products within the NHS.
It is for these reasons that I ask noble Lords not to press their amendments when they are reached.
Amendment 4 agreed.

  
Clause 5: NHS England: wider effect of decisions

Amendments 5 and 6

Lord Kamall: Moved by Lord Kamall
5: Clause 5, page 3, line 15, leave out “The reference in subsection (1)” and insert “In subsection (1)—(a) the reference”Member’s explanatory statementThis amendment is consequential on another amendment which provides that references in new section 13NA of the NHS Act 2006 to effects of a decision in relation to certain matters include its effects in relation to inequalities with respect to those matters.
6: Clause 5, page 3, line 18, at end insert—“(b) the reference to effects of a decision in relation to the health and well-being of the people of England includes a reference to its effects in relation to inequalities between the people of England with respect to their health and well-being;(c) the reference to effects of a decision in relation to the quality of services provided to individuals includes a reference to its effects in relation to inequalities between individuals with respect to the benefits that they can obtain from those services.”Member’s explanatory statementThis amendment provides that references in new section 13NA of the NHS Act 2006 to effects of a decision in relation to certain matters include its effects in relation to inequalities with respect to those matters.
Amendments 5 and 6 agreed.

Amendment 7

Lord Kamall: Tabled by Lord Kamall
7: After Clause 5, insert the following new Clause—“NHS England: duties in relation to climate change etcAfter section 13NB of the National Health Service Act 2006 (inserted by section 5 of this Act) insert—“13NC Duties as to climate change etc(1) NHS England must, in the exercise of its functions, have regard to the need to—(a) contribute towards compliance with—(i) section 1 of the Climate Change Act 2008 (UK net zero emissions target), and(ii) section 5 of the Environment Act 2021 (environmental targets), and(b) adapt to any current or predicted impacts of climate change identified in the most recent report under section 56 of the Climate Change Act 2008. (2) In discharging the duty under this section, NHS England must have regard to guidance published by it under section 13ND.  13ND Guidance about discharge of duty under section 13NC etcNHS England may publish guidance about the discharge of—(a) the duty imposed on it by section 13NC;(b) the duty imposed on integrated care boards by section 14Z43A;(c) the duty imposed on NHS trusts by section 26B;(d) the duty imposed on NHS foundation trusts by section 63B.””Member’s explanatory statementThe new Clause would require NHS England, in exercising its functions, to have regard to certain matters relating to the environment, including climate change.

Baroness Penn: My Lords, in moving Amendment 7 in the name of my noble friend Lord Kamall, I will speak to the other government amendments in his name.
We had a passionate debate on climate change in Committee. There is no doubting the profound relevance of environmental issues to the NHS; indeed, it is already leading the way as a health system in tackling climate change. These amendments will ensure that the NHS can continue in that vital work with the confidence needed to deliver. They place a duty on NHS trusts, foundation trusts, ICBs and NHS England to have regard to the Government’s key ambitions on climate change and the natural environment in everything they do. This could mean preparing thousands of NHS buildings to adapt to climate impacts, protecting and enhancing biodiversity across 25 million square metres of trust estate, or decarbonising the millions of kilowatts of energy used by trusts every year. I must emphasise to noble Lords that this includes decisions about the NHS’s procurement of goods and services. The noble Lord, Lord Stevens, was quite right to underline in Committee that, according to NHS England’s data, the NHS supply chain accounts for some 62% of its emissions footprint. It is clear that the NHS will need to take urgent action to decarbonise procurement.
These clauses will give vital legislative grounding and confidence to the Greener NHS programme and further strengthen the commitments made by the UK through the COP26 Health Programme: namely, to develop climate-resilient, low-carbon health systems. Importantly, Amendment 7 includes a power for NHS England to issue statutory guidance on environmental issues to the system. As discussed in Committee, NHS England already has some targeted net-zero guidance in place for current ICSs, but the system currently lacks that critical statutory guidance that sets the direction for the whole NHS. We expect this guidance, in the first instance, to be issued within 12 months of the Bill receiving Royal Assent.
In developing these amendments, we have had to consider the excellent work NHS England has already undertaken on these issues and gain clarity over what value a legislative solution could add. This has included working across government with BEIS and Defra, while also looking closely at the individual amendments proposed by noble Lords in Committee. I believe the amendments tabled in my noble friend’s name achieve these aims, adding the right value in the right way, to the benefit of our natural environment, the NHS and  the people who depend on it. I pay tribute to the work of noble Lords in helping us reach this position. I beg to move.

Lord Stevens of Birmingham: My Lords, I thank the Government for supporting these amendments, which reflect the substance of amendments that my noble friend Lady Hayman, I and others brought forward in Committee. That debate rehearsed the health case for action very clearly, as we have just heard, so I will not detain the House by repeating that.
However, I think the events of the last 24 hours have underlined two other reasons why these amendments are so important. In addition to the health case, there is clearly a financial case and we also now clearly see the security and humanitarian case for action. The financial case was underlined by yesterday’s IPCC report:
“The financial value of health benefits from improved air quality alone is projected to be greater than the costs of meeting the goals of the Paris Agreement.”
In respect of the security and humanitarian consequences, yesterday, the Government welcomed Shell’s decision to sever its relationship with Gazprom, yet Ministers may have seen an important story in the Health Service Journal suggesting that, over the last two years, at least 17 NHS trusts have continued to rely on gas sourced from Gazprom, which has confirmed today that it continues to get its gas supplies through Ukraine. Decarbonising the health sector will take pound notes out of the hands of dictatorial regimes that are engaged in acts of aggression. For all these reasons, the clarity that these government amendments provide, putting on a sound statutory basis the ability to take fundamental action across the NHS, is most welcome.

Baroness Hayman: My Lords, I declare my interest as co-chair of Peers for the Planet and apologise to the House that I did not declare that interest in my enthusiasm to get involved in a Question earlier today. I added my name to Amendments 7, 28, 87 and 94 and obviously welcome the way in which the Government Front Bench has responded to the debate we had and the amendments we proposed in Committee. As my noble friend Lord Stevens said, there is no point in all of us going through the arguments, although I think he added a new dimension in his remarks today; that interplay between health and climate is an important one that we should not neglect.
The Government have done very well in providing a comprehensive suite of amendments that make sure that the considerations of not just the net-zero targets but the targets in the Environment Act and the needs for adaptation, which will be extremely significant in the healthcare field, will be considered at all the correct levels within the new infrastructure that the Bill brings into place. The assurances that the Minister gave on the guidance that will be published and on making sure that procurement, which is such a large spend by the NHS, will also be governed by these considerations are extremely important.
I welcome these amendments across the board. They weave considerations of climate and the environment throughout the ecology of the NHS, and it is an  excellent result. The next challenge is to persuade the Government to take the initiative on these issues and to embed these considerations throughout their policies and legislation, which would save a lot of time in the House. But I do not wish to be churlish, and I end by simply reiterating my thanks for the way in which the Government have responded to these amendments.

Baroness Young of Old Scone: My Lords, the noble Baroness may wish not to be churlish, but I would regret it if I could not be a little churlish. I declare an interest as chairman of the Woodland Trust and vice-president of a range of environmental and conservation organisations. I thank the Government and the Minister for the assurances given. I also thank the noble Lord, Lord Stevens of Birmingham, for his shuttle diplomacy between the churlish and the less churlish in achieving these very welcome amendments.
I will press the Minister a little further on what she said, just to make sure that we are completely clear. The guidance will be crucial, and I am glad to see that it will be issued initially within 12 months of Royal Assent. I just want the Minister to clarify that the guidance on procurement will cover the need not just to reduce emissions through the NHS supply chain but to secure the other environmental targets, such as those set by the Environment Act. The preamble says that, but I want to make sure there is clarity in Hansard that the guidance will ask for procurement to do not just the climate change job but the other job.
Although the duties on the trusts, ICBs and NHS England include climate change, adaptation to climate change and improving the natural environment, most of the examples the Minister gave revert back just to climate change. The proposed new section in the amendment is headed up:
“Duties as to climate change etc”.
It is the “etc” that I am rather interested in. I think we should spell out more clearly what that is.
Can the Minister assure the House that the guidance will include performance in all three areas—climate change, adaptation and the wider environmental objectives set by the Environment Act and in other places? Because of the massive threat that climate change represents, it is very easy—we all fall into this trap—to squeeze out focus on the other, equally vital environmental areas. We have to remember that if we want to defeat climate change, we also have to defeat biodiversity decline and a range of other environmental factors. I hope the Minister can give these assurances to the more churlish among us.

Baroness Bennett of Manor Castle: My Lords, my speech follows rather neatly from that of the noble Baroness, Lady Young of Old Scone. I will begin not by being churlish but by turning this around the other way and declaring my position as a member of Peers for the Planet and paying great tribute to the noble Baroness, Lady Hayman, who has so led the Government in the right direction on this Bill—as on the Financial Services Act, to think of a recent one before this. I would like to think that maybe it has got a little easier this time than it was on the Financial Services Act, so maybe we are progressing to the point where a Bill will  arrive in your Lordships’ House with climate and environment already there, and we can just focus on trying to strengthen and improve it.
The noble Lord, Lord Stevens, has obviously been hugely important in the progress we have made. He referred to the IPCC report yesterday, which relates to an earlier group we were discussing. The IPCC—I think it is the first time I have seen this—is really explicit about the impact of the climate emergency, and all the events associated with it, on people’s mental health. If we look around the globe at this moment, we see that southern Paraguay is enveloped in a giant ash cloud from fires in Argentina. Queensland and northern New South Wales have record floods, and the city of Brisbane has its second enormous flood in 11 years. That has massive impacts—understandably, through the stress, worry and suffering—on physical and mental health.
I want to particularly pick up the point from the noble Baroness, Lady Young of Old Scone. I noticed, like her, that the Minister said climate and then added environment as an afterthought. Anyone who looks at the Hansard from Committee will see that I very much majored on environment and a couple of aspects of it. Biodiversity is obviously huge, but there is also the issue of antibiotic resistance. The debates between the Minister and me on the Government’s inadequate approach to antibiotic resistance go back to the passage of the Medicines and Medical Devices Act. I also raised in Committee the issue of PFAS—the forever chemicals —and these are huge issues for the NHS.
One final area I raised in Committee was plastics. Before the pandemic I chaired an excellent event seeing some really good progress in the NHS on seeking to reduce the use of single-use plastics. Understandably, that has stalled in the light of the Covid pandemic—for reasons we can all understand. It is really important that that goes back as a focus. There is so much plastic use in the NHS that is easily avoidable, and I would like to ask a very simple question: why is anyone anywhere in the NHS having drinks in plastic bottles? It is the kind of thing that is very easy to get rid of.
I focus on that because I spoke a little in Committee about microplastics. I am going to cite three studies that have come out since then. Microplastics have been found in the placenta and the bodies of newborn babies. Chemicals from microplastics have been linked to obesity; there are studies with mouse fat cells where chemicals from microplastics are promoting the growth of fat cells. Some studies out of China show relative gut health being very closely related to the level of microplastic in people’s bodies. These are studies in the last month.
We have a world choked with plastic. We have a world wildly overheating. We have a world—as the noble Baroness, Lady Young of Old Scone, said—where biodiversity is in collapse. I think the NHS is starting to focus on these things, but we need to see, as the IPCC said, that health and environment are not two separate issues. We live in the environment, and we have to look after it in every part of our activities.

Lord Scriven: My Lords, I rise for the first time on Report and declare my interests as laid out in the register, particularly as a non-executive director of  Chesterfield Royal Hospital NHS Trust and as a vice-president of the Local Government Association. We on these Benches welcome this suite of amendments, with a caveat of clarification that the noble Baroness, Lady Young of Old Scone, raised, to do with not just the climate but the implications for the environment.
The reason we welcome this suite of amendments is that it is vital that there is mandatory guidance from the centre to all parts of the system in the NHS. The only thing I seek to push the Minister on is that she said the guidance would be out within 12 months. I ask that, as we are in a crisis and this is important, it is done as soon as possible. The reason for this—I have experience of it from Chesterfield—is that some of the procurement or building decisions made today will not come around for maybe three or four years, but the design and implications that start today have life cycle implications for both the climate and environment over a long period. So, I strongly push the Minister to ask that the guidance is out as fast as possible, and we do not wait for the whole 12 months.

Baroness Walmsley: My Lords, I, too, am a member of Peers for the Planet and I congratulate the noble Baroness, Lady Hayman, and the noble Lord, Lord Stevens, on their engagement with the Government and thank them for taking their concerns on board.
I have previously raised the fact that a big way in which the NHS can reduce its emissions is by having energy-efficient buildings, and I should like reassurance that any new buildings and refurbishment of the NHS estate will involve highly insulated and low-energy buildings. There are so many things that the NHS can do by using low-energy lighting, reducing microplastics, using compostable single-use plastic or not using plastic at all and using microwaves to deal with clinical waste, because they are much more energy efficient. How will all this be reviewed after the Bill has passed? Will there be any reporting back on how well the NHS has been able to respond to this challenge?

Baroness Wheeler: My Lords, I thank the Minister and welcome these government amendments in response to the key concerns raised in Committee about the crucial importance of including the NHS’s duties on climate change and working towards net-zero emissions in the Bill, and the excellent supportive speeches today.
The amendments take on particular significance in the light of the stark warning in today’s UN report that climate breakdown is accelerating rapidly and there is only a brief and closing window of opportunity to minimise its catastrophic impacts. The duties rightly go across the roles of NHS England, integrated care boards, NHS trusts and NHS foundation trusts in relation to the Climate Change Act 2008 and the Environment Act 2021, and address the need for those bodies to have regard to the need to contribute towards compliance with government climate change and environment targets. Of particular importance is the duty of each body to adapt to current or predicted impacts of climate change and, in Amendment 7, recognition of the importance of NHS England guidance on how the climate change responsibilities are to be discharged within the promised 12 months of Royal Assent.
My noble friend Lady Young sought reassurance that the guidance on procurement will cover not just the need for the NHS supply chain to reduce emissions but also include the key environmental targets. I hope the Minister will be able to reassure her on that.
Strengthening the law to integrate an active response to climate change through every layer of the NHS has been welcomed by the UK Health Alliance on Climate Change, representing more than 900,000 healthcare professionals. Noble Lords made clear in Committee that omitting sustainability requirements from the Bill would have been a missed opportunity to enshrine and enforce the NHS’s historic commitment to reaching net-zero targets by 2040, and we are pleased the Government have recognised that.
As we heard from all speakers, the NHS has made huge progress, but this is just the start and there is much more to do. The amendments reinforce the importance of action in those areas, particularly for the new bodies and processes the Bill creates, and that progress will need to be managed, delivered, tracked and reported at every level.
My noble friend Lady Young’s point, reinforcing that guidance on duties across NHS bodies must include not just climate change but also the improvement of the natural environment, is well made. I look forward to the Minister’s response on that.
In relation to reporting, raised by the noble Baroness, Lady Walmsley, I understand from the contributions of the noble Lord, Lord Kamall, in Committee that progress is being made. He referred to NHS England’s green plans, and we are told that every NHS trust and interim care system is expected to have prepared a green plan and had it endorsed by its governing body. For trusts, the deadline for submission to ICSs was 14 January, so it would be good to know how they have done so far and how many trusts have submitted such plans. The next stage is for ICSs to develop “consolidated system-wide plans” by the end of the month, which will be
“peer reviewed regionally and published”.
Are we confident that ICSs will meet that deadline, and what is the expected assessment and timescale for ICSs to report back to NHS England and, subsequently, more widely on this vital issue?

Baroness Penn: My Lords, I thank all noble Lords for their welcome for the government amendments, and for setting the challenge for the Government that there is always more to do.
I agree with the noble Lord, Lord Stevens, on the additional points that he set out about the importance of decarbonisation, not just for the climate but for health, security and humanitarian reasons. I reassure the noble Baroness, Lady Young, and others, that I did not say that decarbonisation was there to exclude other issues; it is just that that particular point related to that.
I say to the noble Baroness, Lady Hayman, that it is a pleasure to work with her on these issues when we look at Bills, including the Financial Services Bill as it went through, but I have noted her and other Peers’ points about the reactive or proactive nature of the Government’s approach to these issues in legislation.
I can provide the noble Baroness, Lady Young, and others, with the reassurance that they seek that the NHS will have to have regard to wider environmental objectives in developing the guidance, and this includes, for example, biodiversity. That applies to procurement and any other guidance NHS England issues to the system using the new power. In my examples, I mentioned enhancing biodiversity and adapting to climate impacts, so I hope I was not inadvertently too narrow in how I spoke to the amendments.
The noble Lord, Lord Scriven, is right that decisions are being made all the time that will have a longer-term impact, so although I cannot go further than the 12-month commitment, I am sure that the NHS will want to work as fast as it can to bring out the guidance within that.
The noble Baronesses, Lady Walmsley and Lady Wheeler, asked about reporting, both on how the NHS will fulfil its obligations under these duties, and specifically under the green plan. NHS England will report on carbon emissions and progress against its wider objectives. The noble Baroness, Lady Wheeler, asked me a number of more specific questions; if I have not addressed them, and those asked by other noble Lords, I will seek to write after today.
Amendment 7 agreed.

Amendment 8

Lord Kamall: Moved by Lord Kamall
8: After Clause 6, insert the following new Clause—“Information about inequalities(1) The National Health Service Act 2006 is amended as follows.(2) After section 13S insert—“13SA Information about inequalities(1) NHS England must publish a statement setting out—(a) a description of the powers available to relevant NHS bodies to collect, analyse and publish information relating to—(i) inequalities between persons with respect to their ability to access health services;(ii) inequalities between persons with respect to the outcomes achieved for them by the provision of health services (including the outcomes described in section 13E(3)); and(b) the views of NHS England about how those powers should be exercised in connection with such information.(2) NHS England may from time to time publish a revised statement under subsection (1).(3) In this section “relevant NHS bodies” means—(a) integrated care boards,(b) NHS trusts established under section 25, and(c) NHSfoundationtrusts.”(3) In Schedule 4 (NHS trusts: constitution etc), in paragraph 12, after sub-paragraph (1A) (inserted by Schedule 4 to this Act) insert—“(1B) The annual report must, in particular, review the extent to which the NHS trust has exercised its functions consistently with NHS England’s views set out in the latest statement published under section 13SA(1) (views about how functions relating to inequalities information should be exercised).”  (4) In Schedule 7 (constitution of public benefit corporations), in paragraph 26, after sub-paragraph (1A) (inserted by Schedule 4 to this Act) insert—“(1B) The reports must, in particular, review the extent to which the public benefit corporation has exercised its functions consistently with NHS England’s views set out in the latest statement published under section 13SA(1) (views about how functions relating to inequalities information should be exercised).””Member’s explanatory statementThis Clause requires NHS England to describe the powers of certain NHS bodies to process information relating to inequalities and to express its view on how those powers should be exercised. The annual reports for the bodies will need to state how far the functions have been exercised consistently with those views.
Amendment 8 agreed.

  
Clause 14: Establishment of integrated care boards

Amendment 9

Baroness Thornton: Moved by Baroness Thornton
9: Clause 14, page 12, leave out lines 3 to 6 and insert—“(4) Each integrated care board must set out in its constitution—(a) the arrangements for managing conflicts and potential conflicts of interest in such a way as to ensure that they do not, and do not appear to, affect the integrity of the board’s decision-making processes,(b) the process by which any appointment of a member to the integrated care board or any appointment to any committee or sub-committee of the integrated care board that has a commissioning function must be made so as to avoid the appointment of anyone who would be perceived to have a conflict or potential conflict of interest, and(c) the arrangements for ensuring that no member of any committee or sub-committee of the integrated care board who has a conflict or potential conflict of interest obtains access to information that might be perceived to favour the interest or potential interest.”Member’s explanatory statementThis intends to ensure conflict of interest rules that apply to an ICB also apply to commissioning sub-committees.

Baroness Thornton: My Lords, we now come to the group of amendments where the wonderful harmony that has so far filled the House, with all the fantastic concessions and discussions, comes to a bit of an end. It concerns the make-up of the ICBs. I am very grateful to the Minister and the officials for the range of discussions that we have had and, it has to be said, for the consensus that there was and the brilliant initiative by the noble Baroness, Lady Walmsley, which led to Amendment 31. I commend the noble Baroness and the Minister for that amendment, which very successfully looks to the future of how ICBs might work in terms of an audit of the qualities, skills and so on that you need on an ICB. This group, however, reflects the fact that the House is concerned about who serves on ICBs now; they are being formulated and appointments made right now, and the Bill is the only opportunity we shall get to influence who serves on them and how that works.
This group of amendments addresses that issue in various different ways. I feel particularly strongly in my support of the amendment in the name of my  noble friend Lord Bradley, for example. We have had a suite of amendments that have addressed the issue of mental health, but his particularly addresses the issue of ICBs. However, I will allow him to speak to that in due course.
This amendment addresses the fact that in the Commons there was significant discussion and debate about who should and who should not be a member of an ICB—and indeed, agreement was reached about who should not be eligible. Part of the solution came with the amendment which the Minister brought forward then to ensure that private organisations, other than charities, social enterprises and genuine not-for-profit organisations, will be unacceptable as members of the ICB. Employees of a private organisation, lobbyists and those very recently employed would also be barred from being members of an ICB.
That is in the Bill because it was recognised that it was not enough to rely on the governance around declaring conflicts of interest. The Bill is explicit in its exclusion. The current wording of new Section 14Z30(4) says:
“Each integrated care board must make arrangements for managing conflicts and potential conflicts of interest in such a way as to ensure that they do not, and do not appear to, affect the integrity of the board’s decision-making processes.”
Paragraph 4 of new Schedule 1B says:
“The constitution must prohibit a person from appointing someone as a member … if they consider that the appointment could reasonably be regarded as undermining the independence of the health service because of the candidate’s involvement with the private healthcare sector or otherwise.”
There was agreement across the Commons and indeed across your Lordships’ House that that was the right way to move forward.
However, we believe that there is a loophole here. We have discussed this and I have exchanged emails with officials in the department about it, and we believe that the loophole still exists. ICBs will of course be able to set up sub-committees to do some of their work, and those sub-committees can and should be mandated to commission NHS contracts. We believe that the same restriction that the ICB board has on it should be placed on those sub-committees. That is what this amendment centrally concerns.
One of the letters that I received said:
“We anticipate it may be beneficial for a wider range of people to be able to sit on some committees or some sub-committees and NHS England have explicitly asked for this flexibility.”
That reasoning provided made little sense, because it could apply in the same way to the ICB itself. The letter also said:
“We in NHS England think it reasonable to allow private providers to sit on sub-committees of the ICB as barring them risks blocking sensible integration and joint working. For example, if community services in the locality were primarily provided by a private provider it would be unhelpful and damaging to patients to bar an important provider from the committee discussing discharge pathways in that area.”
In fact, the original amendment that was agreed in the Commons was because Virgin Care, as was, got its place on the ICS in its area—which, as we know, was the forerunner of the ICBs—because it was a community provider in that area. So the very thing that caused the  anxiety in the first place and which Ministers claim to have addressed—which they have—is in our view still a loophole. We believe that applying the same restrictions to commissioning at that level is unacceptable and flies in the face of flexibility.
One of the reasons for that is that ISPs will set policy and have the discussion about integration. We have accepted that, given the right kind of governance, of course they should have a range of people on them, including people representing the private sector in that area, because those bodies will not be commissioning NHS services. They will be discussing the appropriate commissioning for the ICB to do for that area. We think that is exactly the right place for the flexibility that NHS England seems to be so concerned about to take place.
I regret having to table this amendment but, after many exchanges—this is not an academic argument—we have been told that much of the ICB’s commissioning role will be delegated to, for example, place-based committees. Those place-based committees will be commissioning NHS services. We suggest that the rules that apply to the ICB should apply also to those place-based committees. So at the moment, unless the Minister has something very different from the letters that his officials have sent me about this matter, we will seek the opinion of the House. I think that is a shame. But ICBs are powerful bodies allocating many billions of NHS funding and influencing many millions as more integrated commissioning takes place. We think that the role of allocating funds in the best interests of patients, carers, service users, the public and the staff should be properly governed and governed by the same rules at local level as they are at ICB level.
The amendments in this group seek to express in different ways the fact that we are still unhappy with the way the ICBs are representing themselves. In Committee, the Minister said to us on several occasions, “This is what the NHS wants”. I think one noble Lord—I do not think it was me—said it was not really the point that NHS England wants this. We are talking about what is best for the locality, the patients and the people in it, and how we best invest and use our NHS money. So what we see in this group is that we are not quite there yet. I beg to move.

Baroness Brinton: My Lords, it is a pleasure to follow the introduction from the noble Baroness, Lady Thornton, of her Amendment 9, which I signed. It is the first of a group on the structure and membership of integrated care boards—including the Commons amendments to which she referred. We agree with the noble Baroness and have concerns about the possible loophole of sub-committees. Before I go into that, I will add my thanks and congratulations to my noble friend Lady Walmsley on her excellent proposals for a skills audit and thank Ministers for agreeing to them. I hope that the Minister will reflect on some of the other amendments in this group that seek to ensure core representation from certain key groups within the NHS.
In Committee we had a lengthy debate on the roles and responsibilities of those who may have current or past connections with private sector providers. A key element of that debate revolved around the duties of  board members and sub-committee members of the ICB to have its duties at the heart of all they do as they commission using public money. In his response to that debate, the Minister said that
“each ICB must make arrangements on managing the conflicts of interest and potential conflicts of interest, such that they do not and do not appear to affect the integrity of the board’s decision-making processes. Furthermore, each appointee to the ICB is expected to act in the interests of the ICB.”—[Official Report, 13/1/22; col. 1308.]
Amendment 9 seeks to clarify exactly what is meant by “each ICB” by looking at the structures for those that make decisions—which includes sub-committees. The noble Baroness, Lady Thornton, described the difficulties in the example of Virgin Care that demonstrate the loophole she spoke of.
I want to go back a step to the principles behind conflicts of interest. In 1995, the then Conservative Government adopted the seven Nolan principles of public life, which are applied to all who hold public office. Members will know very well that these key principles of personal and corporate behaviour are a golden thread running through the public service that any officeholder delivers, and health bodies are specifically included in the rubric of Nolan. All seven principles are absolutely intrinsic to how an ICB and its members will operate, whether at board or sub-committee level. To pick just two, they must have integrity, including not to
“act or take decisions in order to gain financial or other material benefits”,
and they must
“act and take decisions in an open and transparent manner”.
Amendment 9 expresses exactly the type of arrangement that a public-facing body, even a sub-committee that commissions public services, should have in place. I ask the Minister: would any Government not want conflicts of interest in respect of sub-committees of ICBs to be clear, unambiguous and strong? Is he really arguing that each board should not have that wall of protection in ensuring the integrity of its decision-making processes, as set out in proposed new subsection (4)(a)? Does he think that it is appropriate not to have an appointment process that avoids the appointment of anyone who would be perceived to have a conflict of interest, as in proposed new subsection (4)(b)? Does he also not agree that anyone who has a conflict of interest or potential conflict of interest should not have information that
“might be perceived to favour the interest or the potential interest”,
as set out in proposed new subsection (4)(c)? If the Minister cannot answer those questions, I fear that some noble Lords might be concerned that the Government have abandoned the Nolan principles for some people on sub-committees who will make decisions on commissioning many millions of pounds of public funds. I look forward to his response.

Lord Kamall: My Lords, with the leave of the House, I hope that noble Lords will find it helpful for me to speak early in this debate, since we believe that government Amendment 31 addresses some of the concerns raised by noble Lords. I shall, of course, listen carefully to the rest of the debate and respond in full at the end.
In speaking to Amendment 31, I thank noble Lords from across the House for the wide-ranging discussions in the Chamber on membership of ICBs. We are grateful for the discussions. Many noble Lords have offered their gratitude to the noble Baroness, Lady Walmsley, for the suggestion on the skills mix. We accept the spirit of these amendments and agree that it is important that ICBs are populated by members with the appropriate range of skills and expertise. I know that noble Lords have heard this many times, but it is also important that we do not over-prescribe, as ICBs should have the flexibility to design their boards to meet their needs, while also ensuring they have the skills and experience necessary to properly discharge their functions.
We have listened, and I hope that the amendments we have brought forward, which require ICBs to consider these skills, knowledge and experience, address those concerns while also ensuring balanced, workable boards. When the amendments refer to the necessary skills, knowledge and experience, that is in relation to the discharge of all the ICBs’ functions, including those related to mental health, children’s health, public health, public and patient involvement, engagement with the voluntary, charity and social enterprise sector, and digital innovation and integration. Therefore, these amendments would help to ensure confidence that ICBs have the necessary skills and expertise to discharge these functions, while allowing them to retain discretion in how they deliver this. This approach has been welcomed by stakeholders, including the Allied Health Professionals Federation, which represents 12 professional bodies representing allied health professionals.
The second, connected amendment would ensure that an ICB reports on how it has discharged this new duty in its publicly available annual report. This will allow public scrutiny of ICBs and create confidence that they are drawing on an appropriate range of skills, expertise and knowledge. This is in addition to governance of ICBs being clearly set out in their constitutions, which will also be published and signed off by NHS England. As I have said, I shall listen carefully to the rest of the debate, but at this stage, for these reasons, I commend these amendments to the House.

Lord Bradley: My Lords, I rise to speak to this group of amendments, but particularly to move at the appropriate time my Amendment 12. Again, I declare my health interests in the register, especially as a trustee of the Centre for Mental Health and an honorary fellow of the Royal College of Speech and Language Therapists.
As we have heard, we had considerable discussion about membership of ICBs in Committee. I argued in an amendment that membership of ICBs should include a representative of a mental health trust. I also supported amendments stating that allied health professionals—who make up about a third of the health and social care workforce, within which speech and language therapists are a crucial service—should also have membership on the board. However, as we heard, the Government rejected the arguments, principally on the grounds that they made membership too prescriptive and inflexible.
The Minister, with strong support from the noble Baroness, Lady Walmsley, which I welcome, has instead brought forward Amendment 31, which addresses, among other things, the need for an ICB to
“review the skills, knowledge and experience”
of board members and to
“take such steps as it considers necessary to address or mitigate that shortcoming.”
This is clearly very important, and I do not oppose Amendment 31. I certainly hope that, as the Minister indicated, allied health professionals such as speech and language therapists will be part of that review and of the board. But the amendment does not ensure that critical areas of healthcare, particularly mental health, are at the table when the ICBs are established.
Government Amendment 31 is retrospective, looking backward at a possible lack of knowledge and expertise after the event, while ICBs are the crucial forum where decisions will be made about millions of pounds of NHS funding, as well as choices about priorities and system changes. Membership of ICBs really matters from day one. It cannot be left to chance or adjusted inconsistently over subsequent years. Further, I remain concerned that if the voice of mental health is not in the room from the inception of ICBs, there is a danger that the very powerful interests of acute trusts will dominate the agenda, which could lead to undermining the not inconsiderable progress towards parity of esteem between mental and physical health, as we have already heard.
My amendment, on mental health representation, tries to overcome the Government’s criticism of overprescription and inflexibility by proposing that at least one member of the ICB should have expertise and knowledge of mental health in each ICB area. The Centre for Mental Health and the Mental Health Foundation support the view that this has the advantage of not being prescriptive and of not specifying that mental health representation should have a clinical focus or involve the nominee of a particular mental health trust. This could help to contribute to a more rounded conception of mental health, including public mental health representation, user-led representation or community organisation being placed on the board as the advocates for mental health services in their local area. This would help to ensure that integrated care systems do not become remote from their local communities and that the issues that really matter to the people are addressed from day one as the ICB plans its services.
Amendment 31, which would require ICBs to have a balance of skills and knowledge, is certainly a huge step in the right direction. I again commend the noble Baroness, Lady Walmsley, for the work she undertook on this amendment, but it should go one step further and guarantee that none of the 42 ICBs can leave mental health out of the room when crucial decisions are made. My amendment would not constrain ICBs by specifying who can or cannot bring mental health on to the board, but it would ensure that that voice is there and in the room. In doing so, it would benefit everyone’s health and well-being, helping to create a more balanced and effective health and care system in every area, and for all of us.
As the Minister said he would listen to the arguments, I hope he will accept this and, if not, clearly explain why. I will not move my amendment now but certainly will at some point.

Baroness Meacher: My Lords, I support Amendments 9, 10, 14 and 32 and will speak to my Amendment 11, which follows on quite nicely from the contribution of the noble Lord, Lord Bradley. It refers to mental health, public health and secondary care services as vital to be represented on ICBs.
As drafted, the Bill leaves the membership of ICBs very much up to local decision-making. The Minister’s Amendment 31 does not change that; it leaves it up to the ICB to decide what it should look like. My concern is that ICBs may be dominated by managers from a range of organisations, perhaps including private sector health bodies. If such ICBs are established—they are being created as we speak—the Minister’s amendment simply enables them to reproduce themselves over time. There will be a degree of transparency over time, but the amendment ignores key sectors and the need for significant clinical inputs to these boards.
Amendment 31 usefully provides an opportunity for statutory guidance to achieve important objectives. In his letter, the Minister made it clear that statutory guidance will clarify that the ICB’s annual report will cover ICB duties in relation to child safeguarding. I very strongly welcome that. Can he include mental health and public health alongside child safeguarding as very particular services that are too often neglected and really need to be represented on ICBs? If he can agree to include those key services in the statutory guidance, as he has included child safeguarding, I would be very content.
Why are these services so important? As I said in Committee, having chaired a mental health trust for nine years, I am acutely conscious of the importance of high-quality and available child mental health services in particular. Across the country at present, the scarcity of such services means that vast numbers of children with quite severe mental health problems simply never get a psychiatric service at all while they are children. These untreated children will have severe problems for the rest of their lives because of that lack of treatment. It is therefore crucial to have a psychiatrist, who will be very conscious of this, on these ICBs—any psychiatrist will be aware that you have to intervene early if children display mental health problems. That is why I feel so strongly about that; I have watched it happen over years.
Another highly significant field being neglected as ICBs are being formed is public health. As many noble Lords know, I am conscious of the huge impact that effective public health responses could have on drug addiction. Police services are increasingly aware of this and are diverting addicted young people to treatment and away from the criminal justice system. However, this approach assumes that treatment services are available in every urban area, but they are not—they have been dropped or cut. Having a public health consultant on every ICB is crucial if these difficult matters are to be properly dealt with and treatment centres are not just closed because they are inconvenient, or whatever the case may be.
The Government hope to control the growth in knife crime through punitive, serious violence reduction orders. We know from all the research in the field that they simply will not work. The Durham, West Midlands and other police services are way ahead of the game, and more and more police services are following them in showing how best to ensure that violent young people caught up in county lines gangs can be diverted into education and work and away from the criminal justice system. However, that assumes that there are treatment facilities available; otherwise it simply cannot happen. Again, please can the Minister include a public health professional consultant on the ICBs as a recommendation in the statutory guidance, as he has done for child safeguarding. I beg to move.

Baroness Hollins: My Lords, I will speak to Amendments 14 and 32 in my name and that of my noble friend Lady Watkins. I want to give an example from my experience; I declare an interest here as independent chair of an oversight panel, reviewing for the Department of Health and Social Care the use of long-term segregation for children and adults with learning disability and/or autism detained under the Mental Health Act. I have seen the impact of very poor and unaccountable commissioning for this group, with very costly mistakes—costly in money and in terms of lives lost and lives destroyed—because of a failure of commissioning appropriate health and social care in the community.
Some commissioners, frankly, do not have the competencies to do their commissioning job safely. I make this point because—while I appreciate the value of Amendment 31 and its requirement that ICBs would have skills, knowledge and experience, keep them under review and take action if they consider that members are failing in some way—as the noble Lord, Lord Bradley, put it, it is rather looking backwards, or marking their own homework, as I might put it, when they do not know what they do not know. This is the problem and why these amendments propose going a little further.
I welcome the Minister’s statement that ICBs will be required or expected to have the appropriate skill mix and experience necessary to deliver all their functions. I understand that the Government will issue regulations regarding fit and proper person tests, which will apply to ICBs when established, including adherence to the Nolan principles, Without the inclusion of the specific skills and expertise required, however, there will be little oversight or accountability of commissioning competence.
I would like the Minister to think again, and to commit to regulations and guidance that set out the criteria and standards that members of ICBs must possess, recognising the responsibilities that they will have and the impact of their decisions on the health and well-being of some of the most vulnerable people in our society. Commissioners take decisions of extraordinary influence; they spend large sums of public money. Civil service appointments are made in accordance with a competency framework. There is no reason why commissioners should be exempt from meeting specific eligibility criteria—and not just in the clinical sphere but in the commissioning sphere, for which there is currently no professional competency laid out.
To give another example, later this month I will be sponsoring the Second Reading of the Down Syndrome Bill, the Private Member’s Bill from the other place that will require relevant authorities, including the NHS, to take account of the specific needs of people with Down syndrome. During the Committee stage of the Down Syndrome Bill, the Minister committed to
“having a named lead on integrated care boards who will be responsible for the implementation of the guidance in practice.”—[Official Report, Commons, 2/2/22; col. 642.]
Thus, representation of learning disabilities and autism interests on ICBs would be within the context of the duty of ICBs to ensure that they have the necessary skills, knowledge and experience. Much will depend on the guidance issued by the Secretary of State under that Bill, which would fulfil similar obligations, I hope, to those of the autism strategy and the Autism Act 2009.
I reassure the Minister that I and other noble Lords recognise the challenge that the Government have in seeking to ensure that the new ICBs comprise people with the correct skills to enable the board to carry out its functions, but these amendments ask for a slightly stronger approach. I ask the Minister to assure the Chamber that guidance and regulations will address the requirement for criteria to be specified.

Baroness Bennett of Manor Castle: My Lords, I am delighted to contribute to this rich and important debate, and particularly to speak to Amendments 10 and 13 in my name.
Commenting on the words of the noble Baroness, Lady Meacher, about the importance of public health, I would stretch that much more broadly than the examples that she gave. It really ties to the previous group, where we were talking about how climate change and the nature of the environment are related to health. A public health approach really is talking about ensuring that we have a healthy environment, that we prevent illness and malfunction. If we do not have that approach in the ICBs, that is a real problem.
I agree with the noble Lord, Lord Bradley, that government Amendment 31 is useful but not sufficient to deal with the issues that are raised by this group of amendments. The Green group very much agrees with Amendments 9 and 12 and will support them should we get to that point.
I declare my interest as a vice-president of the LGA and the NALC, which may be relevant here. In speaking to Amendments 10 and 13, I declare exactly where I come from. It was the Royal College of Nursing that persuaded me that these amendments should be here. It is very much the college’s case that I now present.
To begin with a little bit of history, as part of the statutory regulations of the Health and Social Care Act 2012, it was mandated that registered nurses would be part of the governing body of clinical commissioning groups. If we look at Regulation 11 of the National Health Service (Clinical Commissioning Groups) Regulations 2012, we see that a CCG governing body must have at least one registered nurse within its membership. This will be lost if it is not required within the leadership of the integrated care boards.
This ties to a point made by the noble Lord, Lord Bradley, that sometimes there are very powerful forces in medicine. It also relates to the points made by the noble Baronesses, Lady Thornton and Lady Brinton, about the powerful force of private interests in medicine. Other truly important voices often get swept aside. It is worth noting that in the NHS in England, registered nurses are more than 49% of all professionally qualified clinical staff. They have a unique relationship with patients and clients which gives them a different insight to other professionals on how the service works, and in ensuring that measurement of performance reflects the interests of patients and clients.
In representative volume terms alone, the case here is very clear. Registered nurses lead, innovate, and deliver the largest proportion of care, and their leadership brings critical expertise, advice and challenge into boards. Without this clinical leadership, there is a risk that service design and delivery become a matter of financial accounting, without proper attention being given to quality and outcomes for patients and clients, or that there is a focus on the heroic interventions rather than on day-to-day care or on the importance of rehabilitation, on which we heard a lot of debate in Committee and which is an area to which our registered nurses bring particular skills.
It is not my intention to move these amendments, but I hope that the Government will listen to the case being put by what is a hugely important professional body and a hugely important body of professionals, and that we see action taken after this debate to make sure that registered nurses are represented.

Baroness Watkins of Tavistock: My Lords, I rise to speak to the amendments in my name and to support those of the noble Baroness, Lady Hollins, who earlier described the need to standardise the knowledge and experience of commissioners, given the potential significance of their decisions.
The Government rightly suggest that there must be some flexibility so that integrated care board membership best reflects the competences needed to commission for local populations. However, unless regulations stipulate essential criteria for members’ collective skills, knowledge and experience, we risk falling into old habits of medical paternalism. That will undermine efforts towards more integrated, holistic care and mental health needs may be given cursory regard. The voices of nurses—as so ably outlined by the noble Baroness, Lady Bennett of Manor Castle—and other professionals will not be heard.
I would like to share with the House a well-known quote in organisational management: “Every system is perfectly designed to get the result it gets”. We now have the opportunity to safeguard the diversity of experience in each integrated care board by establishing a minimum standard, imposed either by regulation or by statutory guidance, to ensure the system gets the result that best meets commissioners’ needs for local patients and populations across the country.

Baroness Whitaker: My Lords, as well as supporting Amendments 9 and 12 and the rest of the group, I would like briefly to add my support for Amendment 31 in my capacity as patron of the British  Stammering Association. This amendment is very much welcomed by the Royal College of Speech and Language Therapists, for all the reasons that we set out in Committee. It would do much to improve the expertise available for these damaging difficulties with the basic human need to communicate and the capacity to swallow, so I hope the Government adopt it—I am sure they will, because it is a government amendment. I am very grateful.

Lord Hunt of Kings Heath: My Lords, before the noble Baroness, Lady Walmsley, speaks, I congratulate her and the Minister on Amendment 31. I also want to ask a question. It very much looks as if the integrated care board is marking its own homework, because the duty to keep the experience of members under review is placed on an integrated care board. It is then for the integrated care board itself to make a judgment as to whether it
“lacks the necessary skills, knowledge and experience”.
Quite clearly, any board that has already appointed a group of members is almost certain, in undertaking its review, to come to the conclusion that it was altogether wise in appointing the members with the balance it did. Who is going to monitor this? Who is going to check?
What if you are a local nursing body concerned that nursing issues are not being debated and reflected enough within an integrated care board? What do you do? Who do you go to? As far as I can see, apart from judicial review proceedings there is absolutely no way you can get any change. That is why—and I pay tribute to the noble Baroness, Lady Walmsley, for her work on this—you need amendments like my noble friend Lord Bradley’s to make some specification in relation to those critical areas where it is essential that the board has members with the relevant experience.
My second point for the Minister is this. In introducing her Amendment 9, my noble friend Lady Thornton essentially said that the Bill already lays out constraints on integrated care boards in relation to potential conflicts of interest. All she seeks to do is to extend that to sub-committees of the integrated care board, including place-based committees, which will commission a huge amount of health service provision in future. For the life of me, I cannot see how those sub-committees can be constituted under any different principle from that of the integrated care board itself. Unless the Minister really comes up with a convincing answer on this, I think the House should make its views clear.

Baroness Harding of Winscombe: My Lords, as this is my first contribution on Report, I begin by declaring my interest as the recently stepped-down chair of NHS Improvement and NHS Test and Trace.
I commend the noble Baroness, Lady Walmsley, and my noble friend the Minister and support Amendment 31. In Committee, we debated in considerable detail the constituent elements of the ICBs. I think it hugely important that integrated care boards have a loud, strong, forceful voice for mental health, public health and prevention in all its forms, but I also think it really important that we enable a board to be a proper board.
The noble Lord, Lord Hunt, questions whether a board would ever assess its own competence and members. Any really good, functioning board in the public and private sector views that as one of its primary obligations. The first line of defence to ensure that a board is performing well is whether it is actually doing an assessment every year of whether it has the appropriate skills. Yes, you should have second and third-line assessments through the CQC and NHS England, but it is the role of a board, and we should let them do that. I believe that Amendment 31 holds these boards to account to do that.
The amendments we have already debated today, enshrining the obligations around public health, health inequalities and mental health, ensure that that is the clear objective of those integrated care boards. I encourage my noble friend the Minister to hold firm and support his amendments and not the others.

Baroness Walmsley: My Lords, I thank noble Lords who have expressed their support for Amendment 31 and my role in it; it is very kind.
I go back to how this arose. It is to some extent influenced by what the noble Baroness, Lady Harding, said in Committee. It was quite clear that many noble Lords were very concerned that appropriate levels of skills, knowledge and experience were on an ICB so that it would be able to carry out all the functions that the Bill puts upon it; not perhaps just the list that the noble Lord, Lord Kamall, mentioned, because it was not intended to be an exclusive list. The amendment actually says:
“in order for the board effectively to carry out its functions”.
I think there it means all of its functions.
It was quite clear in Committee that the Government had set their face against prescribing all the different people who should be on a board. But there had to be a way of making sure that the board had all the necessary commissioning skills, and the knowledge and experience of all the areas of health services which that board had to deliver. The board had to have the duty to make sure it could do all of those things—perhaps without prescribing everything, which the Government are determined not to accept.
The solution came to me not just because of what the noble Baroness, Lady Harding, said but because of what my noble friend Lord Thurso said to me in private—not on the Floor of the House. He is a very experienced board chair. He called my attention to the National Audit Office advice on best practice in this respect and a paper on NHS leadership, which recommends something very similar: that the board must have the duty to make sure it has all the skills, knowledge and experience to carry out all its functions, keep that under constant review and report on what it has done and how.
It is inconceivable to me that, if ICBs had this duty, there would not be somebody who knew everything that needed to be known about mental health and public health to effectively commission those services. The duty to report is very important, to keep this in constant review every year and to report in its annual report on how it makes sure that it has got all those skills and that experience. I think the CQC would look  very carefully at whether the board had actually carried out the duty put upon it by Amendment 31. If there were any gaps in a service which the board had to carry out, and it did not have the right skills, knowledge and experience to do that, the CQC would be very critical. I commend this amendment to your Lordships.
I will also say in concluding that on these Benches we also support Amendment 9. The noble Lord, Lord Bradley, had a very good point. The amendment in the name of the noble Lord, Lord Kamall, which I am supporting, is retrospective because it requires that, by the end of when an annual report comes around, the board has to show what it has done in respect of providing the right people to make the right decisions. From day one, what this House has done on mental health and how important it is, with the Government’s co-operation, is right.

Lord Mackay of Clashfern: My Lords, one has to start with the definition of the functions of the integrated care board in the Bill. It says:
“An integrated care board … has the function of arranging for the provision of services for the purposes of the health service in England in accordance with this Act”—
that is, in accordance with all the provisions of the Act. The idea that you must identify some of them in order that the thing should be perfect strikes me as damaging to the nature of the definition. For example, we had today at Question Time a Question about experts in eating disorders. Ought it be said that we must have an expert with clinical experience of dealing with eating disorders? Is it perfect without that? This is the nature of the board that is being set up: it has a generalised responsibility for all that the Act provides in relation to its area.
So far as Amendment 9 is concerned, it seems to me that the requirement in respect of conflicts of interest is part of the construction of the board itself. Therefore, it must be a restriction, if you like, on every committee and sub-committee of the board, because they are all part of the board and therefore subject to that definition.

Lord Kamall: My Lords, despite what the noble Baroness, Lady Thornton, said at the beginning about this perhaps being the end of the harmonious start to our debates so far, I feel that this has been a helpful and constructive debate. I am grateful to noble Lords for bringing these issues before the House.
Let me start with Amendment 9, as I understand the wide interest in the membership of the committees of the board and potential conflicts of interest. We firmly agree that conflicts of interest must be handled carefully, and have included multiple references to that in the Bill. We also recognise the concern that ICBs should not allow private providers to control commissioning decisions, which is why we added the amendment relating to private providers in the other place, in paragraph 4 of Schedule 2.
Furthermore, in the helpful discussions we have had with noble Lords since then, there has been mutual recognition that we need to balance the importance of protecting the core values and public nature of the NHS while not overly restricting the membership of  ICBs. I am pleased that the amendment to Schedule 2 balances on that tightrope and gives appropriate reassurance. We think that it is reasonable to allow private providers and social enterprises to sit on some committees and sub-committees of the ICB, as barring them risks blocking sensible integration and joint working.
I am also aware of the mixed reactions to this amendment from stakeholders. Many noble Lords will have seen the NHS Providers Report stage briefing, which states that
“there could be circumstances where a local private or voluntary sector provider would be well placed to join a joint committee with a focus on integrated service delivery whereby the usual arrangements to identify and manage conflicts of interest would, and should, apply.”
It goes on to say:
“It does not seem reasonable … therefore to further restrict the membership of those committees in a way which is prescriptive in law.”
Further, the NHS Confederation stated in its Report stage briefing that this amendment
“risks critically undermining integration by reinforcing a rigid, out-dated purchaser-provider split and derailing the fundamental purpose of these reforms.”
As it so eloquently put it:
“The current reforms aim to facilitate collaborative working by bringing all partners in local areas around the table to plan the most effective and the most efficient way to deliver care. This, by its nature, involves bringing providers of services, alongside commissioners, into committees and sub-committees of the ICB to plan how care is delivered”.
Potential conflicts of interest are inevitable in commissioning, especially when we are looking to increase integration and bring multiple bodies together. The ICBs will be required to manage conflicts of interest as part of their day-to-day activities. That is set out in the Bill and will be part of their constitution as well.
For all committees, the board of the ICB will have to determine what functions they exercise, their membership, and the level of oversight of their decisions. The board of the ICB cannot delegate a function and claim to be no longer responsible for how it is discharged, and will be held to account for this by NHS England.
Also, ICBs will be clear and transparent about interests, and how they are being managed. We think that transparency will prevent poor decision-making. New Section 14Z30 makes it clear that an ICB must maintain and give public access to a register of interests for members of its committees or sub-committees. There must be arrangements in place to ensure that conflicts are managed not just for ICB members but within committees. The constitution of the ICB must also include the arrangements to be made to discharge the functions under new Section 14Z30 and a statement of principles to be followed by the board in this regard. This will all be supported by guidance from NHS England. We are quite determined to tackle conflicts head on and not shy away from this issue.

Lord Hunt of Kings Heath: My Lords, if NHS England is determined to tackle conflicts of interest head on, why is it building them into the whole structure of integrated care boards? Let us think about an integrated care board discussing future strategy: it would inevitably discuss where the priorities will be.  That inevitably means that money will follow the priorities. At what point in those discussions do the major providers, who will be sitting round the table, have to withdraw from because of a conflict of interest? At heart, this ambiguity is built in, so it is not surprising that my noble friend wants to see consistency right through the system, including the sub-committees.

Lord Kamall: I thank the noble Lord for that intervention because I was just about to come to it. I should add that new Section 14Z30 very clearly requires ICBs to manage conflicts of interest at sub-committee level.
We think that the approach we have outlined will be more appropriate and possibly more effective than simply barring individuals with a conflict of interest—which, I encourage noble Lords to note, would also include NHS Providers and local authorities— from all committees with a commissioning function. First, this approach is broader than what the noble Baronesses might have intended. Secondly, many committees will have a range of functions, and commissioning may be only a small part of their activity. This approach risks creating a series of duplicated committees with similar interests to enable commissioning decisions to be taken in line with the amendment. This risks undermining one of the very purposes of this reform: to reduce bureaucracy and increase integration.
On Amendment 10A, we are clear that chief executive pay should be value for money. The pay framework is based on our ability to attract the highest-quality candidates. ICB roles, such as the chief executive, are some of the more complex in the health system. Experienced chief executives of trusts already exceed the suggested £150,000 per annum remuneration. Therefore, we do not believe it would be realistic to expect them to take a pay cut to take up a role with such a portfolio.
I remind noble Lords that putting the salary of an ICB chief executive into the Bill would be inappropriate. Such a lack of flexibility would be extremely unusual for a senior position and risks salaries declining in value over time, precisely as ICBs take on more responsibility as they become more established. This would fundamentally weaken ICBs’ ability to recruit and retain senior management. I also warn that directly tying pay to performance is likely to make it significantly harder to recruit chief executives to more challenging ICBs—precisely the organisations that we would want to recruit the very best leaders.
I hope I can reassure noble Lords that the recruitment process will ensure that only the most qualified people can take up these roles. All ICB chief executive appointees across England need to demonstrate how they meet—

Lord Lansley: I am sorry to interrupt my noble friend. I do not think we have debated Amendment 10A; it is not in this group.

Lord Kamall: I wish my noble friend had stood up the moment I mentioned Amendment 10A. I can only apologise. I have received advice to agree with what my noble friend said. I shall very quickly move on and I thank him for his vast experience of this.
Let me move on to a couple of issues raised about mental health. We expect mental health trusts to play a critical role in ICBs and ICPs. The Bill sets out a minimum requirement. It does not specify what sort of care NHS trusts or NHS foundation trusts deliver. As we said earlier in the debate, we hope that ICBs by local agreement go beyond the minimum requirements. We clearly want to see parity of esteem between mental health and physical health.
Noble Lords mentioned public health. The department and NHS Improvement publications have stated an expectation of an official role for directors of public health in ICBs and ICPs. This recognises the vital advisory and leadership roles of directors of public health in the system-wide effort across all domains of public health, which is amplified by the shift to a more preventive, collaborative and integrated systems focus on improving population health. We are working very closely with stakeholders to shape this official role in relation to ICBs.
Can I just check that we talked about Amendments 14 and 32? Yes, we did. This is a more interactive session than many noble Lords would have expected. Perhaps it will do as a sort of novelty. I believe that Amendments 14 and 32 are aligned closely with the skills mix amendment, and I hope that will go some way to satisfying concerns.
On guidance, I am able to reassure your Lordship’s House that NHS England’s regional teams are having ongoing discussions with CCGs and will deal with ICB leaders about the potential membership of the ICB board on establishment. These discussions are focused on ensuring that the board will be effective in discharging the statutory duties of the ICB. Looking beyond this, NHS England is able to issue guidance to ICBs and will engage with them—to understand what issues are emerging during the initial period of operation —and their committees and how they are working with stakeholders. In some areas, NHS England is already developing draft guidance. For example, the proposal is that each ICB will be expected to have a named lead with responsibility for commissioning for learning disability and autism.
On regulations, we think the rules as currently set out in the Bill, and with the addition of the new skills mix amendment, are sufficient and will give ICBs the space they need to develop effective systems in their area. The Bill already includes a regulation-making power that covers any provision related to ICBs’ constitutions, including ICB membership. Therefore, if we deem it necessary in future to be more specific about ICBs’ membership requirements, we retain the ability to do so through regulations. I hope I have been able to provide some assurance—sufficient assurance—to noble Lords and that they will not move their amendments when they are reached.

Baroness Bennett of Manor Castle: I do not believe that the Minister has directly addressed Amendments 10 and 13. I am aware of the time, so perhaps he will agree to write to me about them.

Lord Kamall: That is a very wise suggestion by the noble Baroness, and I will acquiesce to it.

Baroness Thornton: I congratulate the noble Baroness, Lady Bennett, on that suggestion.
I shall be very brief. This was an excellent debate, which proved that the House still has some reservations about ICBs and, if nothing else, it should tell NHS England and the 42 existing ICBs that we want them to do extremely well and to be powerful. Amendment 31 will help ensure their future prosperity and the diversity they need to do their job.
However, I am not content with the Minister’s explanation about my Amendment 9. I regret that NHS Providers and the NHS Confederation never bothered to speak to me about this amendment. They seem to have spoken to the Minister and a few other people and have been on Twitter about it. I think that is rude and it makes me wonder where their panic has come from. I do not think they need to panic about something which just adds consistency to the rules that govern commissioning and the spending of our money. I say with great respect to the noble and learned Lord, Lord Mackay of Clashfern, who I did not see at the beginning of this debate, that if sub-committees are commissioning and spending public money, they should have the same rules as the ICBs. That is the crux of this. I wish to test the opinion of the House.
Ayes 175, Noes 161.

Amendment 9 agreed.

  
Schedule 2: Integrated care boards: constitution etc
  

Amendments 10 to 11 not moved.

Amendment 12

Lord Bradley: Moved by Lord Bradley
12: Schedule 2, page 145, line 30, at end insert—“(d) at least one member with expertise and knowledge of mental health in the integrated care board’s area.”

Lord Bradley: I wish to test the opinion of the House.
Ayes 162, Noes 147.

Amendment 12 agreed.
Amendments 13 and 14 not moved.
Consideration on Report adjourned until not before 8.55 pm.

Gambling Advertising
 - Question for Short Debate

Lord Foster of Bath: To ask Her Majesty’s Government what assessment they have made of the link between gambling advertising and gambling-related harm.

Lord Foster of Bath: My Lords, I declare my interest as chairman of Peers for Gambling Reform. Since gambling advertising and gambling itself were liberalised by the Gambling Act 2005, the promotion of gambling products has grown exponentially, with an annual spend now in excess of £1.5 billion and a growing amount of that happening online. It is worth noting that one in six adults follows gambling companies on social media, as do a surprising number of children.
Also growing has been the level of public concern about gambling companies using ever more sophisticated means to attract new customers and persuade existing ones to spend more, using a range of techniques to keep customers hooked, from disguising losses as wins and celebrating near-misses, to offering so-called free money and free spins. Writing in the Guardian recently, Annie Ashton describes the predatory actions of gambling companies and how her husband Luke committed suicide after relapsing into his gambling addiction. She wrote that
“the pattern of his gambling was obviously harmful. He took advantage of a free bet offer, deposited money, lost money, was immediately advertised another free bet offer, and the cycle would begin again.”
Luke found that being “bombarded with ads” on his mobile
“made it a problem that became impossible to escape.”
It is hardly surprising, then, that earlier this month a group of 50 academics called for “badly needed” restrictions on the promotion of gambling products. They wrote:
“In our opinion it has become quite clear that the gambling products being offered and the ways in which they are promoted are harmful to individual and family health and damaging to national life”,
adding that protecting young people should be a “top priority”, with unprecedented numbers being exposed to gambling advertisements via the internet and television. Their concerns include advertisements on TV, radio, online and elsewhere, gambling company logos on sports kits and in sporting venues, increasingly sophisticated direct marketing to individual customers and the use of sporting celebrities in gambling ads who become role models for vulnerable children.
These academics are not alone. There is a growing clamour for major reform among the public. A YouGov poll last year found that almost two-thirds of adults favour a complete ban on gambling ads and a ban on gambling sponsorship of sporting events and teams. In your Lordships’ House, the 150-plus members of Peers for Gambling Reform want change; just a few weeks ago, the noble Lord, Lord True, speaking in a personal capacity but while at the Dispatch Box, said that as a sports fan he was
“sick and tired of gambling advertising being thrust down viewers’ throats.”—[Official Report, 27/1/22; col. 446.]
Some changes have been made. The Advertising Standards Authority has tightened some rules and, possibly to ward off a tougher crackdown, the gambling industry itself has taken action. The Gambling Industry Code for Socially Responsible Advertising, which is in addition to the ASA’s codes, has been strengthened and includes a whistle-to-whistle ban on gambling ads during televised football games.
Although these moves are welcome, they only chip away at the barrage of messages adults and children see on a daily basis. After all, gambling logos can still appear more than 700 times in a single televised football game, despite the ban, because logos on shirts do not count as advertising. The industry and, at least until recently, Ministers, have used a variety of arguments against further restrictions: loss of income to commercial public service broadcasters and sports clubs, likely growth in black market gambling, and an absence, they claim, of evidence linking gambling advertising and gambling harm.
However, I believe that there are answers to each of these. For example, a ban on sponsoring sporting bodies could be phased in and the loss offset by offering sports rights, where gambling companies pay for the right to offer betting on sporting events. Working with banks, tougher measures against black market gambling could be introduced, although it should be noted that the Gambling Commission has said that the industry’s concerns about black market gambling are overstated.
I want to concentrate on the claim that there is no evidence of a causal relationship between gambling advertising and harm. To make this claim, the industry has frequently called in aid—as did John Whittingdale when he was Gambling Minister—the very limited survey of relevant research carried out by Per Binde in  2014, from which he concluded that none showed a causal link between gambling ads and harm. Yet the operators fail to mention that, more recently, in 2019, Per Binde produced a further study that concluded:
“Gambling advertising may contribute to problem gambling, and problem gamblers are more sensitive to advertising impact than non-problem gamblers.”
Here, and around the world, there is a growing body of evidence to support that more recent conclusion by Per Binde. Following a review of evidence, the ASA, for example, said:
“Several studies … have found associations between advertising exposure and the behaviour of problem and at-risk gamblers.”
It said that some studies produced evidence that was
“robust enough to support the existence of an association between exposure and gambling behaviour”.
A study published in December 2021 in the Journal of Gambling Studies shows that advertising is a predictor of at-risk and problem gambling in secondary school children. A recent Gambling Commission survey found that 34% of British bettors admitted to being influenced by advertising, noting that 16% claimed that ads caused them to increase their gambling. Some 13% said that ads led them to initially take up gambling, and nearly 15% said that viewing ads resulted in them taking up gambling again after taking a break. Earlier this year, researchers at Ipsos MORI and the University of Stirling found that 96% of young people aged 11 to 24 had seen gambling marketing messages in the last month and were more likely to bet as a result.
Under the heading:
“Gambling Advertising has no public benefit and contributes to harm”
the Coalition Against Gambling Ads cites multiple examples of recent research evidence and concludes:
“There is good evidence that, for a considerable number of people, gambling advertising substantially contributes to disordered gambling”.
These are just a few examples of the compelling body of evidence that has built up. It is undoubtably true that more research is needed, but there is now sufficient to suggest that we should be seriously concerned, and that industry claims that there is no link between gambling advertising and gambling harm should be dismissed. I was heartened that, in recent correspondence with me, the Minister, wrote that, “the government remains absolutely alive to the differential impacts and risks that gambling advertising may pose, especially to certain groups such as children and those already experiencing problems with their gambling.”
I am also heartened that, although it took some persuading, the Government now intend that the outcome of their gambling review will be based on a public health approach, just as we already have in relation to drugs, alcohol and tobacco. For gambling, a public health approach should lead to significant curbs on advertising, a ban on direct marketing, an end to inducements such as so-called free bets and the phasing out of sports sponsorship.
With around a third of a million problem gamblers, including more than 60,000 children, 2 million people impacted by it and more than one gambling-related suicide every day, we simply cannot continue as we are.  Major reform of gambling advertising and other marketing measures are urgently needed and, despite what the industry says, are justified by the evidence. I hope the Minister agrees.

Baroness Chisholm of Owlpen: My Lords, if a child or young person has a close friend or carer who gambles, that individual is six times more likely to be a current gambler than those without a connection. We think of gambling as an adult activity but in the UK, 55,000 children aged 11 to 16 are classified as problem gamblers. Gambling has been normalised to such an extent that young people grow up thinking that it is a harmless activity. Clearly, social media has increased the ways in which children can be exposed to gambling, but a study has shown that TV remains the most common source of exposure; and almost all the 11 to 24 year-olds taking part in that study had been exposed to gambling marketing in the previous month. We know that the problem has been exacerbated due to lockdown and the visibility of gambling on social media.
The advertising code forbids the advertising of gambling to under-18s. Almost all forms of gambling are illegal for this age group, so they should not be a targeted audience, but gambling ads are not reaching children accidentally. Advertisers and platforms have access to sophisticated screening tools and accurately target children who are gambling. These ads should not be designed to appeal to children, with an emphasis on fun, cartoons, escapism and winning. E-sports gambling adverts appear to be more appealing to children and young people than adults—the figure is forecast to exceed $1 billion this year with an audience of 500 million, most of whom are children and young people.
The Young Gamers and Gamblers Education Trust, which works with many schools and youth practitioners, has stated that all gambling advertising should be designed and displayed in a way that is appropriate for adults and avoids marketing techniques that appeal to children. Clearly, the advertisers and platforms which host adverts should use technology and data to do more to protect children. We are now seeing a new and complex way of advertising contributing to the normalisation of gambling, as well as attracting young and vulnerable people to its audience.
The Gambling Act needs to consider these new techniques and be able to protect the young and vulnerable from the adverse effects of this new style of advertising. There needs to be far better education and awareness for parents and children, and a better use of age-screening tools. This problem is not going away and arguably, it is a public health issue with serious implications for mental health.

Lord Griffiths of Burry Port: My Lords, our minds are filled with the terrible things which are happening in Ukraine, so much so that it would be easy to push other essential issues out of focus, but we must not allow ourselves to do that. I am therefore grateful to the noble Lord, Lord Foster, for giving us  this opportunity to look again at the question of gambling, and especially the way it affects our children. Despite repeated attempts to stir, prod, dynamite those with power into taking action, we seem to have to go on making the same case again and again.
I am sure many of us share the same feeling of horror when told that there are 450,000 gamblers aged 11 to 16, of whom more than 60,000 are deemed addicts—figures cited by those who have preceded me in this debate. This is not the inadvertent repetition of an old man losing his marbles; it is a statement that needs repeating as many times as it takes to sink into the heads of those with power to act.
As a nation, we are now opening clinics offering advice and support to children and young people suffering from an addiction to gambling. This is, as has been said, a health crisis. We must find the will and fashion the tools to flatten the curve, and a ban on gambling advertising during sports matches is, as has been said, as good a place as any to begin and is long overdue. There is no reason for this not to happen—except, I suppose, for the shedloads of money that the gambling industry pours into the Exchequer every year.
If we know that children and at-risk gamblers are likely to watch sports games, why knowingly put them in harm’s way? An endorsement of gambling by someone’s favourite football team or player must surely influence the opinion of young fans. Legal it may be, at least for the moment; harmful it certainly is. As such, it fits easily among the legal but harmful issues currently being set forth in the online safety Bill.
This is indeed a health crisis: an epidemic. So, I ask the Minister a simple question. If we have the vaccine, the capability drastically to reduce the number of child problem gamblers and the experts begging us to do it, will the Government be part of the mission—or will they content themselves with being anti-vaxxers?

Lord Bethell: My Lords, I am a champion of innovation, and I pay tribute to the gambling industry for the remarkable innovations it has made. I am not a big gambler—I enjoy the odd flutter—but I have seen a massive change in the level of entertainment that people get out of gambling. The industry has driven gambling to new audiences, and the way in which you can now gamble on sports is incredibly impressive. It uses advertising to reach audiences it has never reached before, and the image of the old bookie by the racecourse has been replaced by a high-tech company using the latest algorithms and behavioural techniques.
I must warn the industry, however, that with this immense power—the power of innovation, computers and psychological and behavioural science—comes responsibility. I am extremely concerned that it is in a state of denial about the impact of its innovation, particularly on the most vulnerable. We cannot continue to subsidise the industry for the £1.27 billion-worth of harms that is calculated to be affecting our society. We cannot have the NHS helping to look after tens of thousands or hundreds of thousands of patients with acute gambling addiction. Some 246,000 people are estimated to have severe gambling harm-related illnesses. That is too heavy a load for our society to be carrying.
I ask the industry and the Minister to consider measures to protect two groups in particular. My noble friend Lady Chisholm talked about children, an area that concerns me in particular. With four small children, I know how much access they have to digital communications, and with a strong interest in sport, they are very easily lured into gambling of all kinds. Digital companies, which is what gambling companies have become, owe it to themselves and to society to make sure that our children are protected.
Secondly, the gambling industry has shown a long-standing generational lack of responsibility to those with severe mental illness when it comes to gambling. Time and again, casinos, and now the digital companies, have not stepped up to their responsibilities by cutting off those who cannot afford their own addiction. They should be using innovation and their digital insight to make sure that those who cannot afford to gamble are not allowed to gamble. The fines given to 888, which were in the papers this morning, are disgraceful. An NHS worker who was paid £1,400 a month was given a gambling gap of £1,300. That is not reasonable.
The industry owes it to itself to step up to these responsibilities, and I urge the Minister to look at ways in which the Government can help it do that.

Lord Bourne of Aberystwyth: My Lords, it is a great pleasure to follow my noble friend Lord Bethell, with whom I am in broad agreement. I congratulate the noble Lord, Lord Foster, on bringing this to the Floor of the House, and for the work that he does in this area.
I find myself in broad agreement with the points that have been made. Obviously, an awful lot is encompassed by the concept of gambling; it would include premium bonds as well as raffles and the National Lottery. Cases can certainly be made out for the good that they do, although admittedly with some hazards. Broadly, one can talk about a pleasure concept, which is all to the good, although with dangers to some people. Although I align myself with the Cavaliers rather than the Roundheads on the principle of pleasure, there is a broader public health danger that has been alluded to—and that is the point that we have to address.
I will home in one area that concerns me particularly, which is online gambling, particularly in the context of young people, as alluded to by the noble Baroness, Lady Chisholm. It is done on an industrial scale. Many of these companies are not even paying UK tax, although of course they are causing UK misery and causing the UK massive costs in dealing with these issues—although it is the misery that is clearly of most concern to us. It is high time that these companies were brought to heel. There may be other things that need doing, too—I am sure there are—but, as a first-off, the most important issue is to do something on that front. It is particularly dangerous and pernicious and it is done on an industrial scale. When I google “online gambling controls”, up springs not things that are controlling it but adverts for all these companies, often with names such as “Big Win UK Ltd”, and things like that. So there are great dangers, and I hope that the Government are going to address this sooner rather than later. We so often seem to be playing  catch-up where there is broad agreement, and certainly broad support from the public, to do something in this arena.
As has been said, misery is caused—there are illnesses and suicides, and damage to the home environment and to business. I just cannot understand why we are dragging our heels on this, when there is broad agreement and a massive need to do something, and I hope that the Government come forward with something in this area in particular before it becomes even more serious. It is something that it seems to me we all agree on, but it is the sort of thing that gets overlooked, and I cannot understand why—so I do hope that the Government will press on and do something in this regard.

Lord Vaizey of Didcot: My Lords, I declare my interest as sitting on the advisory board of Sisal, as part of its National Lottery bid—but also, amazingly, I am part of the Behavioural Insights Team advisory panel, looking at problem gambling. I come here not to defend the gambling industry but to defend public service broadcasters—and my noble friend the Minister will know that I am a stuck record on this issue.
Bizarrely, I have had a long association, on and off, with the gambling industry—I say “bizarrely” because I do not gamble at all. But long before I became an MP I worked with Rank, when the Labour Government were proposing super-casinos, and indeed with Victor Chandler when he went offshore to Gibraltar. So, amazingly, I know a bit about it—but not as much as noble Lords who have already spoken.
The point that I want to make as simply as I can is the same point I made when we debated junk food adverts—that I wish the Government and, indeed, many noble Lords would not simply reach for a ban on television advertising as somehow a solution to the problem of problem gambling or indeed of obesity. We need a much more sophisticated and comprehensive approach, and where we can find common ground is to urge the Government to spur themselves into action to provide a comprehensive approach to dealing with problem gambling or gambling excesses. For example, I strongly supported the ban on FOBTs that came into play. To echo what my noble friend Lord Bethell said, I spoke to somebody in the gambling industry who had urged the industry to take action itself, saying that otherwise the Government would take action for it— and the industry did not, and the Government quite rightly did.
So when we consider how to tackle issues such as problem gambling, and indeed the excesses of some gambling companies, please can we look at the online advertising environment, which is too often forgotten in this debate? Television advertising makes far less impact—if you accept that there is an impact—than the much more sophisticated targeting of people, based on their data and visits to websites, that you find online.
Look at the way gambling companies design their sites, and regulate that to ensure that they do not design sites that are attractive and designed to keep you coming back for more. Look at what innovative new banks such as Monzo have done, allowing people to fix their credit card and current accounts so that  they cannot spend money on gambling sites. Work with the responsible gambling companies when they are doing the right thing. I read in the paper today, in the context of Flutter releasing its annual results, that it is apparently linking bonuses for its employees to reducing problem gambling.
So, in the short amount of time each of us is allowed, my simple and heartfelt plea is: please do not keep relentlessly targeting our poor public service broadcasters, which are competing against the likes of Netflix and Disney+, and instead produce a much more sophisticated and comprehensive plan to reduce problem gambling.

Lord Browne of Belmont: My Lords, I thank the noble Lord, Lord Foster, for securing this very important debate. Gambling is a problem right across all areas of our society. It affects people from many different walks of life: poorer people, younger people, military veterans and busy professionals. It often does not discriminate. I have long been of the view that there need to be further measures to protect individuals, their families and communities from the harm caused by problem gambling, such as the stress-related disorders we have heard about this evening.
Many campaigners on tackling problem gambling rightly point to the dangers of online advertising. Gambling companies have increasingly embraced social media as a means of communicating with potential customers. Previous analysis of the public accounts of gambling companies has indicated that around 60% of all gambling advertising expenditure was spent on online advertising. Within that figure there has been a significant year-on-year growth in reliance on targeted advertising on social media and on affiliate social media sponsorship and advertising. Does the Minister recognise the dangers of introductory offer promotion and advertising via social media targeting, particularly on Instagram, Facebook and Twitter? This is still a major issue for problem gamblers online.
Affiliates of gambling companies have a higher proportion of posts in terms of direct advertising. This can be seen clearly when browsing the websites and social media pages of some of our largest sporting teams. Online betting and casino offers such as “Always 10% cashback” and “Claim your free £30 or £50 in free bets” can be found strategically placed on social media posts and images relating to certain football or rugby teams. These often-misleading posts are designed to encourage people to sign up. We know for a fact that many people—regrettably, often those with existing problem gambling issues—are drawn in by these adverts and posts.
It is clear that this industry’s targeted use of social media algorithms specifically is an area that needs to be looked at more carefully. Have the Government any plans to deal with this problem? Have they met recently with Facebook or the other main social media organisations to explore avenues for much more co-operation in tackling these challenges? It is vital that we continue to do all we can, here and in the other place, to highlight and provide that help. It is essential to protect those most at risk from gambling-related harm.

Lord Holmes of Richmond: My Lords, I congratulate the noble Lord, Lord Foster of Bath, on securing this debate. In doing so, I declare my interests, such as they are, as a non-executive director of the Channel Four Television Corporation.
This evening, I will concentrate on the number nine. Nine Premier League shirt sponsors are gambling companies; that is almost half the Premier League. Young people watching a game on TV are highly likely to see a gambling company on the shirts of one of those Premier League teams. If you have one of those fabulous soccer mags we all loved when we were kids, you are highly likely to see a gambling sponsor on the front of their shirts. Successive Governments have banned baccy and booze—does my noble friend the Minister think that problem gambling is less bad?
Following the theme of the number nine, I will concentrate on the 9 pm threshold. What does this mean in modern, 21st-century Britain? Is it that all those who may be attracted and horrifically addicted to problem gambling have all gone to bed before 9 pm? If it were to mean anything, it would have to be much later. Much more significantly, as other noble Lords have mentioned, it means nothing in an era of online platforms. Noble Lords have mentioned the algorithms and technology. The truth about this technology is that it is neutral; it has nothing positive or negative to say about gambling, but what it can do can be horrific and pernicious in the hands of people who purpose that technology and target it. We have to focus on the people driving that technology.
Finally, as your man has it, “When the fun stops, stop”. I ask my noble friend the Minister, for hundreds of thousands of problem gamblers, when did the fun even start?

Lord Smith of Hindhead: My Lords, I thank the noble Lord, Lord Foster, for initiating this important debate. I refer to my interests as set out in the register.
We sometimes risk forgetting in these debates that, for millions of people in the UK, gambling is an enjoyable pastime which causes no harm and is part of the general social cohesion of weekly life. I enjoy the occasional flutter; I play the National Lottery and I enjoy a day at the races. I hope this does not make me a social degenerate.
In many ways, like the noble Lord, Lord Bethell, I want to try to help protect the gambling industry from itself. In an age in which self-governance is always preferable to top-down regulations, I want to encourage, for example, the industry to stop using tipsters and affiliates. Most tipsters and affiliates operate on social media; what they can say or the advice they give are not regulated, and they often make their money when the consumer loses bets. It is hard to imagine any other financial product being permitted to be sold so directly and recklessly. If the industry does not abandon this scheme soon, some type of licensing code will be needed to curb the predatory nature of that part of the business.
Secondly, I am concerned by reports of the number of women seeking treatment for gambling harm more than doubling in the last five years. I am often a bit  shocked when I see an advert for online bingo, for example; it is easy to see how people can be tempted to sign up to these gambling products after watching such colourful—often pink and brightly illuminated—adverts depicting ladies, perhaps with a glass of wine, socialising together at online bingo on their tablets or mobiles with so-called online friends. A very different reality is experienced by thousands of women who, having clicked on almost any of the bingo sites, are besieged by pop-ups, VIP invitations and free monetary vouchers. My understanding of the advertising standards code is that an advert cannot suggest that gambling can provide an escape from personal, professional or educational problems such as loneliness or depression. These sorts of adverts should really be looked at again by those making them and by the advertising regulators.
Lastly—I have raised this in the past—advertising standards on the National Lottery need bringing up to the same level playing field as the rest of the gambling industry. It cannot be right that we expect responsible gambling companies to put warnings such as “When the fun stops, stop” and “Bet to your pocket” while the National Lottery is permitted to use such taglines as “Set For Life”, “Dream Big Play Small” and “The fun starts here”. What the National Lottery is now becoming is not represented by its adverts; it is an online, instant-win, scratch-card gambling brand, more akin to any of the big online gambling companies and not solely the national institution it perhaps once was, selling paper lottery tickets. More work needs to be done in this area.

Lord Butler of Brockwell: My Lords, I am very grateful for this opportunity to speak very briefly in the gap. Owing to the restraint of others, the gap is perhaps a bit longer than I had expected but I do not intend to take very much of it. I am on the executive committee of Peers for Gambling Reform, and I pay tribute to the devoted leadership which the noble Lord, Lord Foster, gives to that group on this subject.
Gambling, like alcohol, is at the same time an enjoyable activity and a dangerously addictive one. When tragedies occur, they all too often start in childhood, and yet we allow advertising on platforms to which children are especially likely to have access. One recent edition of the BBC’s Match of the Day magazine for “footy mad youngsters” featured 52 gambling logos within it. Like others, I am not against advertising, and I am certainly not against football, but I do not think that we should endanger our youngsters in order to support Premier League football clubs or—with great respect to the noble Lord, Lord Vaizey—public service broadcasting. There is a balance to be struck here and I hope the Minister will tell us this evening that the Government are looking for it.

Baroness Bakewell of Hardington Mandeville: My Lords, I congratulate my noble friend Lord Foster of Bath on his excellent speech and declare my interest as a member of Peers for Gambling Reform.
In September 2021, Public Health England published its conclusions on the six harms caused by gambling. These are: financial, relationship breakdown, mental  and physical health, employment and education, criminal and anti-social behaviour, and cultural.
We have heard some powerful speeches this evening. It is attractive to have a little flutter, and this could be quite exciting, but when this gets out of hand it is much more serious. Taking part in fundraising bingo evenings at Christmas and Easter for the local school, where parents give gifts, usually chocolate, as prizes, is a family event enjoyed by everyone. This is a very different matter from a serious gambler who stakes everything on one last throw to see if they can recoup their considerable losses. I hear what the noble Lord, Lord Bourne of Aberystwyth, says about premium bonds—but you do get your money back.
Advertising different aspects of gambling on television gives the impression that it is a social, enjoyable experience, but the reality is very different. It can be a lonely, isolating and often sordid experience for those totally hooked. Often the gambler is aware of their addiction and does everything they can to avoid the temptation, but the offer of a free bet is often too tempting.
Regarding the gambling tax, research by NERA shows that curbing gambling will lead to more jobs, more money for research, education and treatment, and more tax reserves for the Exchequer.
The government response so far has been to review the Gambling Act 2005. In July 2021, DCMS promised a consultation later that year—nothing happened. In January, it said it would be coming soon—a favourite phrase of Governments. The Government further indicated they would consider banning VIP schemes and free bets in their review of the Gambling Act.
While the Government are havering, lives are being ruined and, in extreme cases, lost. Gambling and the advertising that promotes it need to be regulated more strictly than currently. Therefore, my question to the Minister, who has fielded many of the arguments raised this evening on previous occasions, is this: just when are the Government going to review the 2005 Act? Will the review and action be this month, in three months, in six months or never? Can the Minister please commit to a firm date?

Lord Bassam of Brighton: My Lords, I join others in congratulating the noble Lord, Lord Foster, on securing this debate. It seems that it has been shifted around nearly as frequently as the publication date for the Government’s own White Paper on gambling regulation.
Yesterday, in a response to an Oral Question from my noble friend Lord Brooke of Alverthorpe, the Minister seemed keen to hide behind the ongoing review, arguing that he could not “pre-empt” its findings and stressing that we must wait for the White Paper “in due course”. “In due course” seems to have stretched a very long time. That review was launched in December 2020, with the call for evidence closing at the end of March 2021. While we appreciate that the Government have other things on their hands and that they will have received a significant number of responses, accompanied by a raft of data, we are now in March 2022 and are none the wiser about the department’s intentions.
Each and every day, people are exposed to numerous adverts for lotteries, online casinos and sports betting. Much of this is during the broadcast of sporting events, as many noble Lords said, but a significant proportion is general advertising across TV, radio and print. We are all familiar with the proliferation of sponsorship deals with gambling firms in sports such as football, and it remains the case that more than 85% of people report seeing gambling adverts, but other stats should give cause for alarm.
Late last year, market analysis by Nielsen suggested that in a 12-month period, around 1,200 hours of gambling ads, or 100 hours per month, had been aired on radio stations during school-run hours—that is, 8 to 9 am and 3 to 4 pm. Why is it acceptable for children to be exposed to this in this day and age? After being contacted by the Guardian, the owner of Gala Casino reportedly instructed its media buyers to avoid bookings during school-run times. Why has this been left to gambling firms themselves? Could not Her Majesty’s Government have acted before the gambling firms seemed so concerned to act themselves? Of course, the Government need to establish the exact extent to which gambling advertising causes actual harm, but firms would not spend the sums they do—both on placing ads and securing celebrity endorsements—if they were not securing a sizeable return on that outlay.
Voluntary schemes to promote responsible gambling messages may have some impact, but we are still seeing too many people become problem gamblers and ad spending far outweighs funds given to support those who have an unhealthy relationship with gambling. We hope that the forthcoming White Paper will land on our desks sooner rather than later and that it will offer genuine solutions to these problems rather than tinkering at the edges.
Finally, can the Minister say whether the online harms Bill is a potential avenue for picking up some of these issues? We are in need of urgent regulation, and it has been left far too long.

Lord Parkinson of Whitley Bay: My Lords, this has been another very good debate on a topic which I know continues to attract great interest from across your Lordships’ House, as indeed it should. I congratulate the noble Lord, Lord Foster of Bath, on securing it and on the way he opened it this evening.
Clearly, the review of the Gambling Act represents a pivotal moment for gambling regulation, and I am pleased to have the opportunity again this evening to address these issues, although I will not be able to anticipate every element of the review. I will start with the points about timing, as raised by the noble Baroness, Lady Bakewell of Hardington Mandeville, and the noble Lord, Lord Bassam of Brighton.
The gambling review and White Paper have not been delayed. Ministers are working swiftly with officials at DCMS and colleagues right across government on the White Paper. Our review is looking at a very wide range of issues and our call for evidence received 16,000 submissions, which we have been considering carefully, as I am sure noble Lords will want us to have  done. This is the most thorough review of gambling law since the 2005 Act, and we must get it right. We will of course look to implement the outcomes of the review as swiftly as we can.
But we have not waited for the review before taking action to make gambling safer in the meantime where we can. In the last two years, as noble Lords will have heard me say before, we have banned gambling on credit cards, we have tightened restrictions on VIP schemes leading to a reported 70% reduction in the number of so-called “VIPs”, we have made online slots games safer by design, and we have raised the National Lottery minimum age to 18. So, we are taking action as well as carefully considering the review.
Gambling advertising is an important part of that review. The ways in which gambling is advertised and marketed have changed considerably since the 2005 Act. We must make sure that our rules on advertising, like other aspects of gambling, are suited to the digital age; we are determined to get these right as well. The noble Lord, Lord Butler of Brockwell, rightly used the opportunity of the gap to anticipate that striking the right balance in regulation is at the heart of our review; that is, the balance between respecting adults’ freedom to choose how they spend their money and preventing harm to children, vulnerable groups and the community more widely.
In addition to the careful consideration of advertising of gambling in the review, the Government have an ambitious vision for responsible advertising practices in the digital age which goes beyond any single sector. We will consult separately on our online advertising programme, which will establish an overall framework for fair, accountable and ethical online advertising to apply to all sectors.
We already have robust rules on gambling advertising, which, as the noble Lord, Lord Foster, noted, have been strengthened at points over the years since the 2005 Act. All gambling advertising, wherever it appears, is subject to strict controls on content and placement. Compliance with the advertising codes is a licence condition for gambling operators. The Gambling Commission has an overarching requirement that advertising is socially responsible, and that the advertising codes are continually updated in the light of emerging evidence. The commission and the advertising rules ban inducements that encourage customers to gamble more intensely. Operators are not allowed to market directly to people who have self-excluded or customers showing signs of vulnerability.
Since the last gambling review, the Gambling Commission has introduced tough new requirements on operators’ VIP schemes. It has also cracked down on the use of misleading terms and conditions in promotional offers and marketing. The Committee of Advertising Practice has implemented changes to stop gambling adverts appealing irresponsibly to vulnerable adults. A final decision on strengthened rules on content appealing to children is expected shortly. The industry has also introduced the “whistle to whistle” ban, which the noble Lord, Lord Foster, raised, on advertising in live sport. As the noble Lord, Lord Browne of Belmont, mentioned, its code requires adverts in social media to be targeted only at users aged 25 and above and, for YouTube accounts, people aged 18 or over. The noble  Lord, Lord Browne, asked whether we have met social media companies as part of the review. We have done so, at official level.
Turning to the evidence on harm, the noble Lord, Lord Foster, raised the 2019 research by Professor Binde. That research included the statement:
“There is no evidence in this study that gambling advertising in mass media substantially contributes to gambling problems.”
That would seem to confirm that it is people already experiencing gambling problems who are most likely to be affected by gambling advertising, but we do take preventing gambling harm very seriously. We are also alive—the noble Lord, Lord Foster, referred to our recent correspondence—to the disproportionate impact that gambling advertising can have on different groups; in particular, people who are already struggling with gambling problems. We will not hesitate to take action to rule out harmful practices and we welcome efforts to develop the evidence base and our understanding of this relationship.
A number of noble Lords rightly mentioned sport. As well as advertising, our review of the Gambling Act is thoroughly considering the evidence on the subject of gambling sponsorships in sport. We recognise both the concerns about the visibility of gambling brands in sports that are widely enjoyed by people of all ages, including children, and the role that sponsorship can play in supporting elite and grass-roots sport. Gambling sponsorship in sports is one of the areas under close consideration in the review. We are looking at the evidence closely to determine our approach on this issue; no decisions have been made.
My noble friend Lord Holmes of Richmond noted the popularity of football, particularly with children. We recognise the global reach of the Premier League and the upper echelons of football. There are rules in place to ensure that children are not targeted by gambling sponsorship. Sports governing bodies are also empowered to determine what level of involvement with the gambling industry is appropriate for their sport. The noble Lord, Lord Foster, mentioned the correlation between advertising and problem gambling in children and young people. Again, protections are already in place to limit children’s exposure to advertising. Gambling adverts must not be targeted at children or appeal particularly to them. The Committee of Advertising Practice will soon publish more on its plans to tighten the rules in this area.
My noble friends Lady Chisholm of Owlpen and Lord Bethell spoke further on the impact on children and young people. It is important to underline that most forms of gambling in the UK are currently illegal for people under the age of 18. Over the last decade, self-reported problem gambling participation by people aged 11 to 16 has seen an overall falling trend, from 23% to 11%. Those children who gamble typically do so in ways which are legal for them, such as private betting with friends or family. None the less, we recognise that it is essential that our gambling regulation works to protect children and vulnerable people. We have dedicated a chapter of our call-to-evidence to questions in this very important area.
My noble friends Lord Bourne of Aberystwyth and Lord Vaizey of Didcot mentioned the online protections which are necessary. We have made significant progress  in recent years on making online gambling safer, including a ban on gambling on credit cards and new rules to reduce the intensity of online slot games. However, we recognise that more can be done to protect those who gamble online. Our review is looking closely at the case for greater protections for online gamblers, including protections on products and for individuals. The Gambling Commission is also working to improve how operators use data to identify customers at risk of harm and how they can intervene. Operators already must monitor play and intervene when there are signs of harm.
My noble friend Lord Bethell asked about affordability checks. We see a clear role for considering an individual’s financial circumstances to help stop devastating losses, but to be workable and to prevent harm, checks need to be proportionate and be done in a way that is acceptable to customers. We continue to work closely with the Gambling Commission on this issue in the run-up to publishing our White Paper.
The noble Lord, Lord Bassam of Brighton, asked about the Online Safety Bill. Online gambling platforms will be in scope of the regulatory framework if they host user-generated content or facilitate online interaction— for example, through chat functions. However, online gambling platforms which only enable interaction between individuals and the gambling company will not fall into scope of that Bill.
We have a robust regulatory regime which limits children’s exposure to advertising and the effect it may have on vulnerable people, but we, the Advertising Standards Authority and the Gambling Commission are always alert to where more may need to be done. We will be publishing our White Paper at the conclusion of the review and the consideration of all the submissions to it, along with our proposals for reform. We have been carefully considering the evidence that has been received and will continue to take into account the opinions given and further arguments made in debates such as this. I thank again the noble Lord, Lord Foster of Bath, for giving us this opportunity, and thank all noble Lords who took part in the debate. To the noble Lord, Lord Griffiths, the noble Baroness, Lady Wilcox, and my noble friend Lord Bourne, I say, Dydd Gŵyl Dewi hapus.
Sitting suspended.

Health and Care Bill
 - Report (1st Day) (Continued)

Clause 16: Commissioning hospital and other health services
  

Amendment 15 not moved.

Amendment 16

Earl Howe: Moved by Earl Howe
16: Clause 16, page 13, line 42, at end insert—“(ga) such other services or facilities for palliative care as the board considers are appropriate as part of the health service,”  Member’s explanatory statementThis amendment would specifically require integrated care boards to commission such services or facilities for palliative care (including specialist palliative care) as they consider appropriate for meeting the reasonable requirements of the people for whom they have responsibility.

Earl Howe: My Lords, on behalf of my noble friend Lord Kamall, I beg to move Amendment 16 in his name.
The passionate and emotive speeches made on palliative care in Committee left a deep impression on me, as I am sure they did on all noble Lords. Since that debate, the Government have carefully considered the compelling points made by noble Lords from across the House, which we seek to address through this amendment. In moving it, it is right for me to pay particular tribute to the work of the noble Baroness, Lady Finlay, who has done so much to drive this issue forwards.
We recognise that there are variations in access to palliative care services across England. Although we are clear that clinical commissioning groups have always been required to commission appropriate palliative and end-of-life care services as part of the comprehensive health service, we recognise the value of making that clear in the Bill in relation to integrated care boards. We know how important it is that people receive high-quality, personalised palliative care that is built around their individual needs and takes account of what matters to them and those important to them.
These services often include the support of a range of health professionals. For those with more complex needs, this will include access to multi-professional specialist palliative care. These teams provide the essential education and training in the field, supporting research and rapidly disseminating what works. Advice and support need to be available at all hours, wherever patients are, working in an integrated way with other services to ensure that patients can access the support they need early to avoid unnecessary distress.
To make this clear, Amendment 16 would add palliative care services to the list of services that an integrated care board must commission. The amendment clarifies that the commissioning of palliative care is integral to the duty of integrated care boards to commission their part of the comprehensive health service. I am especially grateful for the helpful and constructive way in which the noble Baroness, Lady Finlay, has worked with Ministers and officials to develop this amendment. Without wishing to anticipate her remarks in relation to her Amendment 17, may I just say that, in our view, the kind of detailed provision contained in it would be better covered in statutory guidance, where it can be more fully explained and described? I beg to move.

Baroness Fookes: My Lords, the noble Baroness, Lady Brinton, and the noble Lord, Lord Howarth of Newport, are taking part remotely; I invite the noble Baroness to speak first.

Baroness Brinton: My Lords, I shall speak to Amendment 17, to which I have added my name, but first I thank the Ministers for listening to the noble  Baroness, Lady Finlay, and others, and for tabling Amendment 16. I also thank Together for Short Lives for its helpful briefing.
Your Lordships’ House had a moving debate in Committee that captured the practical and economic need for the wider range of provision of palliative care, and how ICBs can properly fund and plan for it. In Committee, the Minister, the noble Lord, Lord Kamall, said that
“ICBs will be required to have regard to the National Institute for Health and Care Excellence guidelines in their provision of services, as CCGs currently are … NHS England will continue to support commissioners of palliative and end-of-life care services through their palliative and end-of-life care strategic clinical networks. These networks support the delivery of outstanding clinical care by ensuring palliative and end-of-life care is personalised for all.”—[Official Report, 18/1/22; col. 1637.]
The noble Lord’s Amendment 16 provides the specialist services we sought, but it says only
“as the board considers … appropriate as part of the health service”.
Although I join other noble Lords in thanking the Ministers for the amendment, please can the noble Earl confirm that, although the wording of the amendment requires ICBs to commission palliative care “where appropriate”, it is his intention that all ICBs should deem it appropriate, and therefore all of them should commission palliative care services, including for seriously ill children and their families? We know that the provision of palliative care services is very patchy. Will he provide statutory guidance to supplement the amendment and support ICBs to interpret their responsibilities, including for children? When will this be available? What action will Ministers take to ensure that ICBs have the financial resources needed to fulfil the new duty? Finally, what action will the Minister take to ensure that there are enough professionals with the skills and experience needed to provide the palliative care for children that ICBs will have a duty to commission?
We covered all this in very moving stories in Committee. Can the noble Earl confirm that all I have outlined will be covered in regulations and statutory guidance?

Lord Howarth of Newport: My Lords, I am embarrassed to be called to speak ahead of the noble Baroness, Lady Finlay. I understand that the Deputy Speaker does not have discretion to make their own judgment about the sequence of speakers, but I hope this rule can be looked at. As it is, I add my thanks to the Minister, the noble Lord, Lord Kamall, for tabling Amendment 16. He and the noble Earl have graciously paid tribute to the noble Baroness, Lady Finlay of Llandaff. I am sure I speak on behalf of everyone by saying: so should we all. Her vision and persistence have beaten a path towards the progress we can now make.
Although the noble Lord, Lord Kamall, observed in his letter to us that it has always been a duty of the NHS to commission appropriate palliative and end-of-life care services, and that commissioning palliative care is a core function of integrated care boards, these obligations have hitherto been honoured perhaps as much in the breach as in reality. Provision has been patchy, shall we say? I think the noble Earl said that there had been “variations”; indeed there have.
I also acknowledge that the NHS does sometimes provide exemplary palliative and end-of-life care. Many noble Lords will know that my partner Patricia, Lady Hollis, died of cancer in 2018. I express my deep appreciation of the quality of palliative and end-of-life care she received at the hands of the NHS. I particularly express my profound gratitude to her NHS consultant at the Norfolk and Norwich University hospital, Nicola Holtom, and her team, and to others providing community services, because it eased Patricia’s path and made a huge difference to all of us who cared for her.
Sadly, for all too many, including cancer patients, this quality of service has not been available. Indeed, for some there has been no relevant palliative care and end-of-life service. This could therefore be a historic moment, but it is far from certain that it will be. I of course accept that Ministers are acting in good faith, but the indeterminate drafting of Amendment 16 leaves rather a lot of wriggle room. For an NHS which is always short of the resources that it needs and that is struggling to cope with its existing workload, it remains a danger that the provision of palliative care will be sparse. The language of Amendment 16,
“such other services or facilities for palliative care as the board considers are appropriate”,
does not make it clear that it will be an inescapable duty of ICBs to ensure that palliative and end-of-life care is a universal service and that there will be a duty on ICBs to provide high-quality palliative care.
The Minister indicated that he does not expect to agree to write into the legislation Amendment 17, in the name of the noble Baroness, Lady Finlay, which specifies in very useful detail what the nature of an exemplary service would be. He said that it would be better to do this by way of guidance. I am encouraged at least to know that it is the department’s intention to provide guidance and to set out models of how ICBs should set about fulfilling this duty. But what measures will be in place to ensure that this happens? What monitoring does he envisage? What reporting requirements will there be?
I have another question which I think is very important: how will the system enable patients and families to know what palliative care is available for them and how to access it? As things are, so often patients and their families are bewildered. They just do not know where to turn amid the complexities of the system, and they often feel discouraged by the responses they receive. They seem to observe the buck being passed between the NHS and social services and between different entities within those services.
I know that Ministers want to do the right thing, but it is important that we do not miss this opportunity to bring about the real thing. If we can be assured that the quality of provision will be as high as that envisaged in the noble Baroness’s Amendment 17, and that the department and NHS England will have systems to ensure that that is so, this could indeed be a transformative moment—a moment after which there will be the prospect that, instead of experiencing a bleak death, as so many people do, they will have a good death, and that will be an enormous consolation to their families, for whom, in their bereavement, the passing of a loved one is the greatest suffering.

Baroness Finlay of Llandaff: My Lords, I must declare that I am a vice-president of Marie Curie and of Hospice UK. I am most grateful for the kind and generous words that have already been said about me and the work on this amendment. I must thank both Ministers, the team and the officials for all the work they have done on this subject. I also thank the charities Marie Curie, Sue Ryder, Hospice UK, Alzheimer’s Society and Together for Short Lives, and particularly those people who have generously shared their experiences of supporting someone they love who is living with a terminal illness.
Palliative care is not an add-on or aftercare, but must be integrated as an essential part of NHS provision. As we move forward, I want to pick up the point that the provision of services for people who need palliative care must include specialist palliative care as core. Specialist care is provided by multiprofessional teams. These doctors and nurses have specialist training, usually working with allied health professionals who also have become specialised in their way. Hospice care assistants in health and social care have also been specially trained, and others, including multidenominational services and counselling and bereavement support for children and adults, are all part of the wider provision.
People need support in every setting, whether at home or in a care home, hospital, hospice or some other community setting, which includes places such as prisons. In all these settings, the specialist palliative care team works with local clinicians to provide expert advice at all times of the day, every day, supporting health and social care professionals who are providing care to the person and their family. Sadly, as has been said, palliative care is currently patchy, and it must be available wherever people are, as the noble Lord, Lord Howarth, said in his remarks. It must be available for all ages, to reflect on the comments of the noble Baroness, Lady Brinton.
My Amendment 17 sets out the criteria for specialist multiprofessional palliative care services, based on the World Health Organization commissioning guidance. I hope it will act as a guide to all integrated care boards in determining what they will now commission and from whom. In many areas, their local hospice services will be able to have a better contract, spelling out what is expected of them and what is available to them by better integration. In some other areas, services will need to be grown and developed over time.
The charitable hospice world is committed to working with the NHS in an integrated way, leaving the charity free to fundraise for whatever additional, non-core services should be provided to improve the quality of life of patients and their families in their area. Where there are specialist beds, usually in a local hospice, they need to be able to take patients on an urgent basis, as disease does not respect the clock or the calendar.
Specialist palliative care has an important role in supporting the education and training of the health and social care workforce in the area at all levels, as has been said, as well as supporting and participating in relevant research and disseminating evidence-based innovations for rapid rollout. As services develop and move forward, being linked to a What Works centre   initiative will help ensure that there is rapid dissemination of new knowledge and skills. Integrated palliative care services can provide support to ensure the right skilled workforce, equipment and medication are available, with a point of contact for people with palliative care needs if their usual source of support is not accessible.
This is all in place in some areas already, with appropriate systems to share information with the person’s consent, to ensure that all professionals involved know about that person’s needs and what matters to them and their family. As services develop, that will be of great benefit in ensuring that the core team members, if provided through a hospice, have honorary contracts so that they can go into NHS hospitals and provide support as needed, as we saw during the peak of the pandemic. At that time, it was said that palliative care had come into its own, providing support in intensive care units, high dependency units and emergency departments, as well as in the community and on wards.
May I share with the House the fact that I have had correspondence of jubilation from colleagues in palliative care, because this recognition means that they feel they finally have equal status with other NHS services and can integrate better, whether with oncology, neurology, cardiology, surgery, anaesthetics and many other services? Such integration can ensure that patients get what they need when they need it, whether it is radiotherapy to relieve bone pain or halt a spinal cord compression or an urgent nerve block or a surgical opinion.
We are at a milestone moment, and I sincerely hope that this amendment really will be game-changing. It is the start of a new journey, and this is the first step for the Department of Health and the NHS to guide integrated care boards as they look to develop over time the services that their local population need. Now delivery plans need to be communicated to integrated care boards and providers as they work together on the journey to integration and ensure fair access for all to the palliative care that people desperately need, often at the most vulnerable time in their life.

Lord Hunt of Kings Heath: My Lords, I pay tribute to the noble Baroness, Lady Finlay, for her outstanding work in this area. I was very moved by the remarks of my noble friend Lord Howarth in tribute to the care given to Baroness Hollis, who was such a tremendous force for good in your Lordships’ Chamber over many years.
Can the noble Earl clarify the point that has already been raised? In the letter from Ministers of 26 February it was said that the amendment would add palliative care services to the list of services that an ICB must commission. On the face of it, the amendment seems rather more permissive. Proposed new subsection 3(1) in Clause 16 states:
“An integrated care board must arrange for the provision of the following to such extent as it considers necessary to meet the reasonable requirements of the people for whom it has responsibility”.
There is then a list, which starts with “hospital accommodation”, which the ICB must arrange for—then on page 17 are a couple of provisions that seem rather more permissive.
The nub of the issue is this: we have fantastic palliative care in the mainly voluntary sector as well as in the National Health Service itself, but it is very patchy. The health service has been very reluctant to give long-term certainty to hospices and other providers of palliative care services, insisting on short-term contracts. The real question to the noble Earl is this: will this change as a result of this amendment? Where is the beef that will actually get the message across that we expect the health service to do a lot better than it has been doing in support of palliative care services?

Bishop of London: My Lords, I declare my interests in the register. I join in thanking the Government for having listened in Committee. I hope that this will make a difference not just to the lives of those whose lives are shorter but also their families, so it is very welcome. I pay tribute to the noble Baroness, Lady Finlay, but also to my friend, the right reverend Prelate the Bishop of Carlisle, who put his name to Amendment 17.
As I say, I welcome this amendment. As the chair of the UK Commission on Bereavement, I have been reminded recently of the inconsistency of palliative care, which other noble Lords have spoken of this evening. It affects not only those who require palliative care but also their family and friends, and it leaves a legacy into bereavement, which we should not underestimate. I too was reassured to hear the Minister say that palliative care must be commissioned, but I share again the concern of the noble Lord, Lord Hunt. In Amendment 16, the word “appropriate” is used, and it is not quite the same thing. Could the Minister reassure the House about the Government’s expectations regarding the nature of palliative care services that the ICBs will commission? How will they ensure that that is delivered in a way that creates consistency? It is care that is rightly deserved by people in our communities, which also reflects the skill and hard work of our palliative care practitioners

Baroness Fraser of Craigmaddie: My Lords, I too congratulate the Minister and his officials on listening to the House and the strong representations he received in Committee on this issue.
I welcome the Government’s amendment. I add my tribute to the work of the noble Baroness, Lady Finlay, as well as the many Members of this House and the campaigns of organisations such as Marie Curie in getting us to this point. It is wonderful that the symbol of Marie Curie is a daffodil, and we are here today on St David’s Day being led by the noble Baroness, Lady Finlay of Llandaff. That is very appropriate.
I disagree with the noble Lord, Lord Howarth of Newport—this is an historic moment and a huge step forward. It is the first time in the history of the NHS that there will be an explicit requirement to commission palliative care. I declare my interests as chair of the Scottish Government’s National Advisory Committee for Neurological Conditions and a trustee of the Neurological Alliance of Scotland. Many people with long-term, progressive conditions have not been able to access palliative care at an early enough point. Not only would this ensure better outcomes for patients, but it would also be a better use of NHS resources. I hope that the result of the Government’s amendment  will ensure that these people get better care, including the palliative care they need. I also hope that ICBs will recognise the difference that they could make.
I welcome the opening remarks of my noble friend Lord Howe about taking the criteria set out in Amendment 17 in the name of the noble Baroness, Lady Finlay, and to which I was happy to add my name. It provides a helpful set of guidance for ICBs to follow, based on standards. I echo the question of the noble Lord, Lord Howarth, on ensuring that we have the right reporting requirements. I am grateful to hear that the Government will be developing statutory guidance to ensure that we put the necessary tools in place. However, I have been concerned to learn, in my meetings with NHS England, how—as far as I have been able to ascertain—it reports on services, rather than medicines or specific procedures. When reporting on NICE guidelines for services, NHS England seems to rely on “noise in the system” to ensure whether they know that something is happening or not. I share some noble Lords’ worry about the word “appropriate”. If we develop statutory guidance based on the criteria set out in Amendment 17, I hope that the risks that the word “appropriate” might continue to see a postcode lottery will somehow be allayed.
Finally, given that ICBs are at different stages of their development, can the Minister and the department give careful consideration to the ongoing and direct communication to ICBs regarding this duty? Will they consider writing to all ICB chairs to ensure that they are fully aware of the duty and their responsibilities?
The Government have made a very important step forward today in giving people who are facing the end of their life the reassurance they and their families need. The focus now must be on ensuring that this amendment is used to its fullest by the ICBs, so that everyone who needs palliative care will benefit.

Baroness Meacher: My Lords, I shall speak briefly to add my very strong support for Amendment 17, promoting the provision of specialist multiprofessional palliative care services. I also welcome, and will comment on, the Government’s Amendment 16 on the same topic. Alongside all other noble Lords, I pay tribute to my noble friend Lady Finlay for her tireless work to improve palliative care services.
It is of course most welcome that the Government have tabled an amendment in this field, but their amendment leaves it to the ICB to decide what standard and extent of palliative care services are “appropriate” to meet what they deem to be the “reasonable” requirements of their populations—the Government’s words. What do these terms mean? Does the Minister accept that the amendment does not ensure that adequate specialist palliative care services will be available across the country? That is what we all desperately want to see. I hope that, in his response, the Minister can define these terms. What do the Government mean by “appropriate” palliative care services and a “reasonable” level of such services?
As I said in Committee, it is unbelievable that the NHS provides services according to need throughout our lives, until we are dying, when of course our health needs are at their greatest. At that stage, precious  hospices have to raise their own money, as others have said in the past, to finance their doctors and nurses to care for the dying. Inevitably, hospital beds lie empty. Some 50% of beds in a hospice I visited recently were empty, because it simply did not have the staff to deal with patients in those beds. Can the Minister confirm that the Government will provide statutory guidance to supplement Amendment 16 and clarify what they mean by the terms “appropriate” and “reasonable”?
As things stand, I strongly support the amendment tabled by my noble friend Lady Finlay. As we die, we should all have high-quality palliative care services. We can then expect that, when assisted dying is legalised, a reasonably small percentage of dying people will suffer unbearably, despite benefiting from top-quality services, because of course there are situations when the best possible palliative care services have done everything they possibly can and yet certain patients suffer unbearably. We need a change in the law to ensure that those patients have control over the suffering that they can reasonably tolerate.
I look forward to the Minister’s response and, as I say, hope that he will clarify the definitions of the terms used in the amendment.

Lord Mackay of Clashfern: My Lords, this amendment adds a new paragraph to the new Section 3(1) set out in Clause 16 and it seems clear that what Section 3(1) says refers to all that follows it:
“An integrated care board must arrange for the provision of the following to such extent as it considers necessary to meet the reasonable requirements of the people for whom it has responsibility”.
One has to look at reasonable requirements in relation to everything in that list, with the first being “hospital accommodation”. The idea that there might be some areas with no hospital access at all is absolutely ridiculous. So this is a qualification, to be fitted in as paragraph (ga).
Immediately before it is another provision, which refers to services considered
“appropriate as part of the health service”.
That seems to suggest that it is absolutely essential that the needs and reasonable requirements of people who need palliative care are met. ICBs do not need to provide palliative care for the whole community, but are required to provide it for the proportion of people expected to require it, namely those getting near the gates of death. That is a reasonable interpretation of this clause.
I believe it goes quite a long distance in the way that the noble Baroness, Lady Finlay, and others for some years have asked for. I do not think it feasible to say that nobody in an area will require palliative care—unless its inhabitants are people who live for ever, of which there are only very few. It looks to me as though this is well constructed to ensure that palliative care must be provided where people die, in the area of the integrated care board.
I entirely welcome Amendment 17 from the noble Baroness, Lady Finlay, but the crucial amendment is provided by the Government and is written in a way that will be very difficult for any care board to try to escape, because it is very clear.
I also join the noble Lord’s tribute to Lady Hollis, who was such a tremendous source of value in this House, including, as many of your Lordships will remember, the time when she was able to get the House to set aside the order about capital provision for poorer people.

Baroness Hodgson of Abinger: My Lords, I will be very brief. Having spoken on this in Committee, I simply thank my noble friend the Minister for bringing forward Amendment 16 to include palliative care services in the list of things required by ICBs to commission. We all agree that the end of life is one of those times when care is needed most, and I too congratulate the noble Baroness, Lady Finlay, on all her work on this, and all those who spoke in support in Committee.
This is an example of where the Government have truly listened and responded to concerns voiced on all sides of the House. They have made the most of the Bill’s unique opportunity to ensure that nobody with a terminal illness misses out on the care and support they need, both now and in the future.

Baroness Walmsley: My Lords, I congratulate the noble Baroness, Lady Finlay, without whom this amendment would not have been laid by the Government —although I pay tribute to the Government for listening to her. As she said, it could be game-changing—I say “could be” because unless the resources are made available for these services and for training enough of the health professionals needed to carry them out and make them available everywhere, it will not be game-changing. I would like a reassurance from the Minister that adequate resources will be made available so that, as appropriate, ICBs can carry out the duty that will be put on them.
I was horrified to hear the noble Baroness, Lady Meacher, mention a hospice with half its beds empty. I hope additional resources will be provided for hospices. I clearly remember somebody saying in Committee that you would not expect to have a coffee morning or a cake bake to treat a broken leg; you should not have to do the same sort of thing for services at the end of life. I hope the Minister will bear in mind the possibility that additional resources should go there.
We have heard that services are patchy across the country, and I suggest that the worst patchiness is in services for people dying at home. I know it is not easy to provide 24-hour services and advice to a family doing their best to try to care for somebody dying at home, but it must be done. I am afraid I know friends who have had a very bad experience of that. The person at the end of life had a bad experience, and the family have never forgotten it. As the noble Baroness, Lady Finlay, has often told us, it is possible for everybody to have a good death if the right services are provided to them. That means a good experience too for the family, who simply want to know that they have done the best and that that has been enough.

Baroness Merron: My Lords, from these Benches I am very glad to continue our support for palliative care being part of a comprehensive health service—literally from the cradle to the grave—no matter who you are, your age or where you live. I join other noble Lords  in paying tribute and giving appreciation to the noble Baroness, Lady Finlay, for her assistance and professionalism over many years. I hope that the real tribute to the efforts of the noble Baroness will be in the delivery of real change to the quality of people’s lives—and their deaths. I add my appreciation to all the charities and hospices that have also been a force for good in seeking this change.
I welcome the government amendment in this area and, in so doing, I simply say to the Minister that I hope the Government have heard the number of questions asked today. Clearly, there is concern about the words “appropriate” and “reasonable”, and I will add a few questions to those already put to explore that further. I am sure the Minister understands that noble Lords are simply trying to ensure that what is intended will actually be delivered.
Can the Minister confirm how the Government’s expectations will be conveyed to ICBs, and how they will understand what is expected of them in terms of the nature of palliative care services that they would be required to commission? It would also be helpful if he could commit to providing a definition of “specialist palliative care” services, referring to the amendment tabled by the noble Baroness, Lady Finlay, so that we can see a consistent standard in provision of services across the country. My final question is: can the Minister confirm that it is the Government’s intention to communicate to all ICBs that they should fulfil the true requirements of this amendment, and can he tell your Lordships’ House how this will be monitored?
The right reverend Prelate the Bishop of London and other noble Lords have made it clear that we would like the matter settled by the amendment, but it is not entirely. I hope that the Government will not lose the opportunity to really make the transformation so that we can all expect, and have, a good death, as we would want to have a good life.

Earl Howe: My Lords, I am very grateful to all noble Lords who have spoken in this important short debate, but, in particular, I express my thanks to the noble Baroness, Lady Finlay, for the illumination that she shed on the reality of well-functioning palliative care services from her personal perspective.
Without repeating what I said earlier, the Government recognise and understand the strength of feeling on the issue of variation among access to palliative care services. I understand the line of questioning posed by a number of noble Lords on the strength of the imperative implicit in the government amendment. The noble Baronesses, Lady Brinton, Lady Meacher and Lady Walmsley, and the noble Lord, Lord Hunt, all had questions on that theme.
The first thing for me to say is that I agree with the noble Baroness, Lady Finlay: this is a game-changing amendment because it would specifically require—that is the word—integrated care boards to commission such services or facilities for palliative care, including specialist palliative care, as they consider appropriate for meeting the reasonable requirements of the people for whom they have responsibility.
Questions have been asked about the word “appropriate”. I do not think any other word could be fitted into this context; you have to talk about what is  appropriate when the extent of need and the requirements of the local population inevitably vary according to the locality. It is for the board to judge what is appropriate to meet that need in the local area and what is appropriate to the nature of the palliative care provision that may exist in an area: for example, whether it is a hospital, a hospice, social care hospices or hospices at home—all the panoply of palliative care provision that noble Lords will be familiar with. My noble and learned friend Lord Mackay of Clashfern made a very helpful intervention on that issue, for which I thank him.
We therefore expect palliative care to be commissioned by every ICB. It will be for them to allocate resources to meet the needs of their population that they identify but, on funding more broadly, the House will know that there is a multifaceted funding pattern in the palliative care field. Palliative and end-of-life care services are delivered by services and staff across the NHS, social care, the voluntary and community sector and independent hospices.
We recognise the vital role that hospices and other voluntary organisations play in the delivery and funding of palliative and end-of-life care and continue to engage proactively with our stakeholders on an ongoing basis to understand the issues they face. Those are not bald words; as part of the NHS Covid response, over £400 million has been made available to hospices since the start of the pandemic to secure and increase additional NHS capacity and enable hospital discharge.
The noble Baroness, Lady Brinton, asked me about statutory guidance. A range of guidance is already available to commissioners about the provision of palliative and end-of-life care, including detailed, evidence-based guidance from the National Institute for Health and Care Excellence. We will continue to keep the guidance under review. NHS England and NHS Improvement have also made funding available to seven palliative and end-of-life care strategic clinical networks, which will support commissioners in the delivery of outstanding clinical care, with sustainability of commissioning as a guiding principle.
The noble Lord, Lord Howarth, and my noble friend Lady Fraser touched on transparency and reporting. I point to our later amendments requiring ICBs to set out how they intend to commission services and report on that in their annual reports. That will of course include palliative care. I can also give an assurance that we are not only looking at the guidance currently but will continue to keep the range of guidance available to commissioners under review.
In answer to the noble Baroness, Lady Merron, on the Government’s expectations in this area, I can say only that our expectations as of now are set out in this amendment and in the guidance we will issue, and the assurance that we will engage with in our dealings with NHS England.
I hope I have been able to reassure the House that the Government are absolutely committed to ensuring that people receive high-quality palliative care if and when they need it. I invite the House to support Amendment 16.
Amendment 16 agreed.
Amendment 17 not moved.

  
Schedule 3: Conferral of primary care functions on integrated care boards etc

Amendment 18

Baroness Hollins: Moved by Baroness Hollins
18: Schedule 3, page 159, line 16, at end insert—“116C Primary ophthalmic services for people with learning disabilitiesNHS England must make arrangements for the assessment of the need for primary ophthalmic services by people with learning disabilities, including access to sight tests, and ensure primary ophthalmic services are commissioned to meet those needs, including in special schools.”Member’s explanatory statementUnder Schedule 3 of the Bill, NHS England retains its powers to make arrangements for the provision of primary ophthalmic services itself or direct Integrated Care Boards for such provision. This amendment seeks to improve eye care for people with learning disabilities including in special schools.

Baroness Hollins: My Lords, I rise to speak to this amendment on behalf of my noble friend Lord Low, who is unable to move it because of a failure of his technology. I commend my noble friend’s sustained advocacy of the issues raised by the amendment. I declare my interest as founder and chair of the charity Books Beyond Words, which has published a word-free book called Looking After My Eyes jointly with the charity SeeAbility, which briefed my noble friend and me on this amendment.
The amendment seeks to improve primary ophthalmic services for people with learning disabilities, including pupils in special schools. There is no system of national monitoring of the number of people with learning disabilities who have visual impairments. Some research has estimated that people with learning disabilities are 10 times more likely to have serious eye problems than the general population, and six in 10 people with learning disabilities need glasses but may not recognise that they have sight problems. They may not be able to communicate this effectively, and they certainly need reasonable adjustments to access ophthalmic services.
The prevalence of visual impairment increases with the severity of someone’s learning disability. We know that some conditions associated with a learning disability, such as Down’s Syndrome, are associated with specific causes of visual impairment such as cataracts. My noble friend commented in Committee that the charity SeeAbility had identified that “four in 10 children” in special schools
“had never had a sight test”
and that
“half of adults with learning disabilities had not had a sight test” —[Official Report, 20/1/22; col.1837.]
within the recommended period. In short, those most in need of high-quality eyecare are arguably those least likely to get it. We need targeted improvements in primary eyecare for all people with learning disabilities. I am therefore very pleased to support my noble friend’s amendment and, in his absence, I beg to move.

Baroness Thornton: I just want to say that I think that that is perfectly correct and reasonable.

Baroness Penn: My Lords, I am very grateful to the noble Baroness, Lady Hollins, for introducing this debate on behalf of the noble Lord, Lord Low. I am the first to agree that the provision of primary ophthalmic services for people with learning disabilities is important. This is indeed why the majority of people with more severe learning disabilities are already likely to be eligible for free NHS sight tests.
However, we recognise that more needs to be done in this area to improve access to services. For that reason, the NHS Long Term Plan made a commitment to ensure that children and young people with a learning disability, autism or both in special residential schools have access to eyesight checks. NHS England commenced a proof of concept programme in 2021-22 to further pilot access to sight tests in special schools. Any future national commissioning model will be informed by an evaluation of this pilot, and I ask the noble Baroness to accept that we need to wait for its learning before pushing too far ahead. NHS England will continue to engage providers in the development of any future programme of work beyond the existing proof of concept, and I am sure that the Minister for Primary Care and my noble friend Lord Kamall would be happy to meet the noble Baroness and the noble Lord to discuss the programme further.
Finally, I remind the House that the imperative to improve access to these services is part and parcel of the duties placed on ICBs and NHS England to reduce inequalities in accessing health services and inequalities in health outcomes. The work NHS England has undertaken in this space demonstrates how seriously it takes these duties. I hope that, on the basis of the answer I have been able to give and the Government’s commitment to update noble Lords on the future development of this service, the noble Baroness will be content to withdraw this amendment on behalf of her noble friend.

Baroness Hollins: I thank the Minister for her sympathetic response to the amendment. I appreciate the importance of waiting for proof of concept, as was spelled out.
One of the remaining issues, of course, is that training in how to adapt services for people with learning disabilities is also important. However, I hope that the proposed mandatory training in learning disability and autism will help to address that further. On that basis, I am content to withdraw the amendment.
Amendment 18 withdrawn.

  
Clause 20: General functions

Amendment 19

Lord Farmer: Moved by Lord Farmer
19: Clause 20, page 16, line 12, at end insert—“14Z32A Duty to prevent illnessEach integrated care board must exercise its functions with a view to preventing the development of poor physical and mental health, including by ensuring health services are available in a community setting where possible, in order to improve access.”Member’s explanatory statementThis amendment would ensure the prevention of ill-health was prioritised including by making health services available closer to patients’ homes to lower barriers to access.

Lord Farmer: My Lords, in reintroducing this amendment, I want to pick up on comments made by my noble friend Lord Kamall in Committee. He said that he agreed with “the spirit” of my amendment and had been reassured since becoming a Health Minister by
“the number of people in meetings who have said that they want to move towards a focus on prevention.”—[Official Report, 20/1/22; col. 1811.]
Although the duty to improve continuously the quality of services and obtain appropriate advice includes those in connection with prevention, this in no way guarantees that it will be raised up from the current low bar relative to treatment.
I do not think it misuses the important concept of levelling up to apply it in this context. The thrust of my amendment is to level up the emphasis on addressing the precursors of illness with delivering care while it runs its course, as well as with what comes after, whether that is its sequelae, rehabilitation or palliative care. After all, the NHS is the National Health Service. Keeping people healthy and preventing ill health should be the first duty of integrated care boards, thereby fulfilling the purpose of the NHS. The chronic waiting lists and ever-increasing costs, which seem never to end, both flow from a culture that is reactive rather than proactive.
As my amendment states, a duty to prevent could mean, in many contexts, community health provision. A reverse Beeching for healthcare would help to nip in the bud any developing conditions and, when health needs have family implications, enable them to be treated alongside and integrated with early family help. Prohibitively long journeys to hospitals, in respect of which ICBs might choose to integrate health and health-related services to reduce inequality of access, will work against this prevention imperative, hence the need to give it primacy. A couple of examples will be helpful here. I will touch on how preventing, for example, childhood obesity and mental ill health will in no small part require improving family relationships, which is best done in the community.
The Leeds child healthy weight plan, established and led by Public Health England but multiagency in approach, focuses on prevention as it can be more difficult to engage families and see improvement once problems arise. Families on the plan took healthier steps in both the consumption of fruit, vegetables and sugary drinks, and physical activity, but they also reported a reduction in screen time and increased parenting confidence. Leeds has seen child obesity rates among reception-age children decline significantly as a result, particularly among the most disadvantaged children, over a period when similar cities and England have seen no change in this key area.
Secondly, in a recent major study of more than 43,000 children in children and young people’s mental health services, over half cited family difficulties, which were the biggest presenting problem. Again, community-based family support is vital for preventing mental ill-health.
In concluding—as noble Lords can see, I have not spoken for long—I want to stand back from this. The tragic events in eastern Europe indicate the need to spend more money on defence. Where will it come  from if we do not cut our cloth differently? The prevention of ill health has to be a part of that. I beg to move.

Lord Crisp: My Lords, I will speak to Amendments 33, and 37 to 54. I thank the noble Lords who have added their names to those amendments.
There is a very simple point here. The purpose of these amendments is to make sure that primary care is as highly influential in the new system as, and not the poor relation of, NHS trusts and NHS foundation trusts. It is vital for the whole success of the entire Bill moving forward that primary care is able to play its proper part in the future. It is therefore very good indeed that the Bill includes having a representative for primary care on the board of ICBs—the integrated care boards. However, I will turn to the problem, which is exemplified by the first of these amendments.
Amendment 33 refers to a passage in the Bill which says:
“Before the start of each financial year, an integrated care board and its partner NHS trusts and NHS foundation trusts must prepare a plan setting out how they propose to exercise their functions in the next five years.”
There is no mention of primary care in that, which is where the amendment comes in, adding the words “and primary care”. It is worth just noting that this is an entire reversal of what is in a sense the current situation, where primary care has a big role within planning and the acute and NHS trusts more generally have a much lesser one. So this is a very big change. My first question to the Minister is that it would be helpful if he would explain why NHS trusts and foundation trusts are being treated differently from primary care. Alongside that, why and how will he make sure that primary care will be able to function as it should do in being equally influential with the other sectors?
I have already outlined the reasons for this in very broad terms, but I will pick out three or four points. First, it is so that their contribution can be made. Primary care is not just about what is happening in the out-of-hospital sector; it also has a significant role in what should be happening in the hospital sector and, of course, to pick up the point made by the noble Lord, Lord Farmer, it has a major role in prevention as well. Secondly, this is about morale. Primary care has very poor morale at the moment, and anything that seems to downgrade its role is important.
Thirdly, it is about messaging and the priority that is being given to the different parts of the system. Fourthly, there is another point here. Over the last—I guess—25 years, a number of GPs in particular have become quite adept at planning, thinking about the future and commissioning and so on. There is a great wealth of experience there, and that is experience of planning not just for primary care but for health services, and indeed prevention more generally. Then, of course, as I said at the beginning, this is about the direction of travel.
I am pleased to say that I have had some good discussions with the Minister, and indeed with officials, and I look forward to hearing what the Minister will be able to say in response to this. My request, and that of the noble Lords who have added their names to the amendment, could not be simpler. Why is it intended  to treat NHS trusts and NHS foundation trusts differently, giving them apparently a more central role, and how will the Minister give the same level of influence to primary care as the Bill does to these other bodies?

Baroness Finlay of Llandaff: My Lords, I have an amendment in this group, but I support the thrust of the debate so far. I should declare that I am a fellow of the Royal College of General Practitioners, having previously worked as a GP.
The noble Lord, Lord Farmer, stressed the importance of trying to prevent ill health later on and to bring a population up to be less unwell than the current population is. We have to have a very strong primary care workforce to manage people in the community. There has been a great move to try to move people out of hospital and back into the community, but primary care is currently creaking under the load and social care services are not there to provide much of the support these people need. So primary care has to be factored in as a major contributor, the more we expect people to be looked after at home, nearer home and in the community. That can be particularly difficult in rural areas, where GPs are expected to take on much broader responsibilities. They might even be managing some of the accident services in the area, working with the ambulance services.
The amendment I have tabled is about rehabilitation. Part of the reason for it being in this group—I think it is appropriate that it is—is that recovery from any episode will require a period of rehabilitation. That must be factored in. People will need physiotherapy expertise, occupational therapy, and speech and language therapists. They might need podiatry. They might need to have technology supplied to them to manage their condition at home, and to learn about managing it. The patient and the family themselves might need education in how to manage their rehabilitation and recovery.
When a person is clearly through the critical phase of whether they are going to survive a major accident, they then have a very long haul of rehabilitation, which might take years and might require ongoing support if they are ever to realise their true potential within the limitations. There have been some astounding examples of catastrophic injury where people have gone on to contribute enormously to their own families and in life, but they have needed intensive rehabilitation services over a long time.
So my amendment is there to ensure that this does not get forgotten in the way that services are commissioned and planned for, and so that rehabilitation is viewed as an integral part of the follow-on after the acute phase, as people get home, transition from hospital into the community and look towards resuming their life. It might well be very different from the life they had before, but this would enable them to fulfil their potential.

Lord Scriven: My Lords, I support the amendments in the name of the noble Lord, Lord Crisp, to which I have added my name. I think the noble Lord  had to table these amendments because the Minister said when we discussed this in Committee that his challenge was to ensure that
“primary care is better represented and not dominated by acute trusts.”—[Official Report, 20/1/22; col. 1854.]
We expected something to come back that did exactly that, because the very fact the Minister said that suggested that the Government had accepted that there was a potential imbalance with the role of primary care.
I come back to the purpose of the Bill, which I did a number of times in Committee. The purpose of the Bill is to bring about effective integration, improve health outcomes and reduce health inequalities. That is underpinned by making primary care central to healthcare planning and ideas about healthcare, following through on those plans and having primary care as an equal partner in the ICB. So we moved away from who we want on the board to asking very simply for primary care to be treated as an equal in the planning, implementation and monitoring of what will happen in health and social care in the area. It is disappointing that, despite the Minister’s suggestion that he would go away and look at this, nothing new has come back since Committee to deal with that.
What new has come back on Report which makes sure that primary care can be better represented and not dominated by acute trusts in this new system? My worry is that the Bill giving this to NHS acute trusts and foundation trusts signals which are most important within the system. If primary care does not have that equity, there will be unrealistic expectations and uninformed decisions made in planning for final decisions and tactical, not transformational, systems and services, which will not represent the full view of primary care. It is for those reasons that I support the amendments of the noble Lord, Lord Crisp, and look forward to the Minister bringing to the House’s attention what new proposals are in here on Report to do with the challenge that he set himself: to ensure that primary care has a bigger voice and is not dominated by the acute sector.

Lord Hunt of Kings Heath: My Lords, I added my name to the amendments of the noble Lord, Lord Crisp, and echo the remarks of the noble Lord, Lord Scriven, on the Minister’s offer in Committee to go back to see how the potential dominance of acute trusts could be mitigated by ensuring that the voice of primary care was heard loud and clear in the various decision-making bodies.
It is a pity that it is a very late hour, because primary care warrants a much wider debate, given the challenges it undoubtedly faces. We are all aware of the workforce issues, such as the reluctance of many GPs to take on partnerships and that so many GPs will do only part-time work, partly because of the pressures. It is because of those challenges and because primary care is so valued in this country that we need some assurances that the people running the new system being introduced through this legislation will be concerned with and listen to primary care.
It is somewhat ironic. The noble Lord, Lord Lansley, is not here any more, but in a sense, we are seeing a transformation from what he hoped would be a GP-led system through clinical commissioning groups to one  which looks very strongly acute care-led in the integrated care boards. As someone who was spent quite a lot of my time in the health service around acute trusts, I do not particularly worry about acute trusts being listened to, because we depend on them so much. We really need assurance that integrated care boards will take primary care seriously.
Finally, whatever concerns and reservations we on this side of the House had about clinical commissioning groups, some GPs undoubtedly rose to the challenge of leadership within them. I should be very concerned if they were lost from the new arrangements. It would be good to know that the Government recognise that and will ensure that a place is found for them in the new system.

Baroness Whitaker: My Lords, I rise to support Amendments 30 and 34. On Amendment 30, I echo the widespread concern of the professional bodies and expressed by the noble Baroness, Lady Finlay, that rehabilitation should be a core service in the NHS. It is inseparable from healing, and healing is often impaired if rehabilitation is not there.
On Amendment 34, it will be important to know whether the proposed integrated health boards will be in contact with services outside the NHS where health can be a critical factor, such as education and criminal justice. As we said in Committee, many speech and language professionals are not NHS employees. How will they be brought into the integrated system?

Lord McColl of Dulwich: My Lords, I shall speak to Amendment 62 in my name and those of the noble Baronesses, Lady Hollins and Lady Walmsley, and the noble Lord, Lord Jones of Cheltenham. I thank them, and the Alzheimer’s Society and Alzheimer’s Research UK, for their support of this amendment.
People with dementia will be one of the largest groups of people to see the benefits of the integration of health and social care services and, therefore, the benefits from the Bill. Currently, there are 900,000 people living with dementia in the UK and, without a disease-modifying treatment available after diagnosis through the NHS, they get the majority of their support through the social care system.
This amendment relates to Clause 21, which ensures that integrated care partnerships prepare an integrated care strategy. These new strategies will be a powerful way to bring together various currently disparate bodies to work towards the same aims. Topics discussed within these strategies will be given consideration across the health and social care systems, consideration that too often people living with dementia have lacked, leaving them falling through the cracks between the various systems. This amendment therefore suggests that each strategy should explicitly consider the needs of people living with dementia. There are two areas where integration could provide particular benefits, which I will touch on briefly.
The first is diagnosis. A diagnosis is incredibly important for people living with dementia, as it allows them to plan for the future, arranging their housing and care needs, putting themselves forward for clinical trials and ensuring that they have first access to the most innovative treatments, while also unlocking access  to vital extra support in the short term. This does not just help the individual. By providing the right support at the right time, we can reduce pressure on the NHS. That is why NHS England rightly has a target that two-thirds of all people living with dementia will have received a diagnosis. This was consistently met from 2015 until the pandemic. As people visited their GPs less frequently, clinicians were diverted to other areas and individuals had little access to memory clinics. The rate dramatically fell from 67.6% in January 2020 to just 61% in January 2022. This has meant that, according to NHS data, an extra 35,000 people are now living in the dark about their dementia status. As we address the backlogs in elective treatment and cancer care, it is vital that we also tackle the backlog in diagnosis of dementia. To do so, we must have clear strategies in place, at local and national level.
I am proud that the UK is seen as a world leader in dementia research, as many noble Lords know very well. However, there are still barriers to us reaching our potential, including a lack of participants for research. This is not because there is low interest in participating in research among the public. According to Alzheimer’s Research UK, 69% of the public would be willing to take part in dementia research. However, 81% did not know how to volunteer. The NHS, as a single health system, has many advantages which give it great potential for data sharing between research and clinical practice, connecting those who want to take part in studies with those conducting the studies.
A valuable report recently released by the All-Party Dementia Group, Fuelling the Moonshot, recommended that all newly diagnosed patients receive a letter from the NHS within three months of diagnosis, explaining how they can take part in dementia research. Integrating dementia research with integrated care partnerships will provide other benefits. The benefits should, and would, flow in both directions. While research can benefit from better access to participants, it should also ensure that innovation, whether in treatments or models of care, can reach people living with dementia.
With no treatments available, we cannot ignore the vital role of encouraging dementia prevention and ensuring that individuals look after their brain health. In discussing the possible causes of dementia, obesity raises its ugly head once again. Researchers at University College Hospital studied a group of participants from the English Longitudinal Study of Ageing. Each participant was at least 50 years old when they were enrolled in the study. Their measurements, including BMI and waist circumference, were collected, and the participants were studied on average 11 years later to determine whether they had developed dementia. The researchers found that participants who had a BMI corresponding with overweight or obese were more likely to develop dementia. Obesity has also been found as a risk factor in several previous studies.
Research has also shown that the number of dementia cases worldwide could potentially be reduced by a staggering 40% if the 12 modifiable risk factors for the condition could be completely eliminated. The Lancet identified that the three modifiable risk factors with the largest potential impact were hearing loss, low  education in early life and smoking. Not everyone who smokes will get dementia, but stopping smoking is thought to reduce the risk down to the level of non-smokers. While there is no sure-fire way of preventing dementia, advances in dementia research have shown that there are steps that we can all take to keep our brains healthy and reduce our risk of developing dementia. The dementia research sector can continue to build on this work with the right support from various sources. However, efforts to improve both dementia research participation and diagnosis rates will amount to little without action taken at national level as well.
The Department of Health and Social Care is currently preparing its updated national dementia strategy, which has been much delayed by the pandemic. At its heart, it must have two main focuses, much like local strategies: diagnosis rates and dementia research. On boosting research, it would be remiss of me not to mention the need to deliver urgently on the promise of the 2019 Conservative manifesto to provide a “dementia moonshot”; that is, a doubling of government funding provided to dementia research. If we are to improve the lives of people living with dementia, we need not only determination from local and national government but strategies for how to deliver these ambitions. Whether it is delivered through this amendment or through other means such as the strategy, dementia care should get the co-ordinated planning that it deserves.

Baroness Hollins: My Lords, it is a pleasure to add my name to the amendment tabled by the noble Lord, Lord McColl. I am not going to say very much in support, because the background has already been explained. Without a diagnosis, people living with dementia cannot access the community support they need.
I will add one specific group who experience dementia, which is people with Down’s syndrome. Some 60% of people with Down’s syndrome will develop Alzheimer’s by the age of 60. A lot of research on Alzheimer’s has been developed from an understanding of Down’s syndrome and the changes that take place in people’s brains. The manifesto pledged to double the funding for dementia research. The amount is interesting. It was a commitment of £800 million over 10 years for dementia research. To put that figure into context, the co-chair of the APPG on dementia, Debbie Abrahams, has stated that dementia currently costs our economy £34.7 billion each year. I therefore support this amendment requiring integrated care partnerships to include a strategy to improve both the diagnosis of dementia and dementia research, which has the potential to improve the lives of so many people in the UK.
I also added my name to the amendment in the name of my noble friend Lady Finlay. I, too, began my medical career as a GP. I therefore support my noble friend Lord Crisp’s amendments. It also has some relevance to my later practice in psychiatry. Having worked as a general practitioner in south London, I began to understand the importance of social factors in the development of mental illness and in the ability of my patients to live with whatever long-term condition they might have. As a community psychiatrist I have extensive experience of practicing medicine that addresses people’s biological, psychological and social needs,  and I have been a prominent advocate of the least restrictive practices. Best practice includes facilitating robust, multidisciplinary mental health care in the community where it is a feasible alternative to treatment in hospital and, when admission is needed, helping people to be discharged back into the community at the earliest point so that their recovery can continue in the community, close to family and friends. As a mother, I advocated for effective community rehabilitation for my daughter after she become quadriplegic, which was a much better option than the nursing home care that she was initially offered.
Robust integration between multiple disciplines within health and social care is essential to ensure the high-quality, coherent, consistent and readily accessible community rehabilitation that can promote physical and mental health and help people to thrive to their full potential within communities. I am very pleased to support my noble friend’s amendment. I should declare an interest as president of the Royal College of Occupational Therapists, a profession which has a particular contribution to make in community rehabilitation.

Baroness Hodgson of Abinger: My Lords, before I speak to my amendment I would like to put on record that I particularly support my noble friend Lord McColl’s Amendment 62, which considers the needs of those with dementia. I also support the thrust of the amendment tabled by the noble Baroness, Lady Finlay, on better rehabilitation. Perhaps the concept of convalescence, as it used to be called, would help free acute beds and thus save money. I also support the amendments tabled by the noble Lord, Lord Crisp, to ensure that integrated care boards work with primary care and, I hope, with community nursing as well.
Amendment 177 is in my name. Much of the Bill is about the architecture of the NHS, and it is important that we get it right. However, the success of the Bill will be whether it delivers for patients. As we have discussed before, healthcare needs to be patient focused. At the moment we sadly have a system where the traditional idea of a family doctor who knows their patients is too often disappearing. Why has this been allowed to happen when we know it worked so well? We need somehow to get an element of that back. I understand that today many doctors in general practice find their role far less satisfactory, with fewer people wanting to go into general practice. I am given to understand that a large element of this has to do with the fact that fewer doctors know their patients, whereas in years gone by they would know and look after the whole family and be part of the community.
With people living ever longer, looking after older people so that they can stay healthier for longer is critical, as is ensuring that they receive the care they need and have a dignified and secure old age. This amendment would introduce a new clause that lowers from 75 to 65 the age at which every patient is assigned a named GP, which would help with prevention, an issue raised by my noble friend Lord Farmer in his amendment. The amendment would also ensure that named GPs actually have to meet and have some knowledge of each patient they are responsible for, and to communicate directly with them and their family.
I will not reiterate all the facts and figures I gave in Committee. I merely remind your Lordships that studies have shown that, quite simply, being treated by a doctor who really knows you can be life-saving. Quality care by a named GP benefits patients by delivering continuity of care and therefore better healthcare, and by keeping more people out of hospital, relieving some of the burden on the NHS.
Following the debate in Committee, I have added proposed subsection (2) to enable the role of the named GP to be “delegated” to another doctor in the practice who might be chosen and preferred by the patient. But this amendment ensures that patients will have someone who actually has some knowledge of them and whom they or their relatives can turn to for help, care and advice.
I was very disappointed that, in Committee, my noble friend the Minister failed to grasp the significant difference between current regulations, guidance and what happens in practice. I have personal proof that, as things stand, some named GPs are able to choose not to know the patients they are responsible for. This amendment seeks to positively address that.
I urge the Minister to reconsider and accept these proposed changes to the Bill. I absolutely agree with the noble Lord, Lord Hunt, that primary healthcare is incredibly important. This whole area really needs an in-depth debate because it is breaking down in some places.

Baroness Walmsley: My Lords, I will make just a few comments. I put my name to the amendment of the noble Lord, Lord McColl, which I will not say much about because he and the noble Baroness, Lady Hollins, have said it all.
However, I will make one point about the importance of early diagnosis. As most noble Lords will know, Alzheimer’s is a complex range of diseases, and it is very important for the patient that their doctor is able to know what sort of Alzheimer’s they have so that an appropriate set of support can be prescribed. The other very important reason is that we do not yet have a disease-modifying cure. Unless more suitable patients go forward for clinical trials, the researchers will not be able to do their research, no matter how much money the Government put forward. We know that 80% of people who put themselves forward for a dementia clinical trial have to be rejected because their disease has progressed too far. So, we really need early diagnosis so that the researchers have some chance of finding the cure that we all want.
Secondly, I will say two things about primary care. The noble Baroness, Lady Hodgson, talked about patients having to see a doctor they have never seen before within their practice. Well, now—and I would like the Minister’s answer to this—not only are people ringing up and going to a doctor in the practice whom they have never seen before; in London, they are now being referred to a completely different practice, because something like five practices share patients. I understand that that is a temporary measure during the pandemic, but could the noble Lord confirm that that is the case? Could he also confirm that it is going to end once we believe the pandemic is over, which of course it is not yet?
I shall say a few words about the amendment proposed by the noble Lord, Lord Crisp. It is vital, as he rightly said, that primary care has a role in planning the commissioning of services. As the noble Lord, Lord Hunt, said, a lot of expertise has been developed, and it must not be lost. It is vital because primary care services are the gateway for a patient to everything else in the health service; it is the first port of call for a patient and, without a referral from a GP, on the whole you cannot get to anything else.
I very much support what the noble Lord, Lord Crisp, is doing and look forward to hearing what the Minister has to say about the reasons why primary care services do not appear to be treated equally with NHS trusts and foundation trusts.

Baroness Thornton: My Lords, this is an important group, so it is a shame that we are discussing it so late in the evening. It is important because it contains essential broad things that people need to stay well in their community. It is about the bread and butter of people’s health—their GPs, dentists, the physios and pharmacists, getting podiatry services and getting the proper social care that you need to be able to stay in your home. It is literally about helping people to stay local and stay well. In many ways, that is why I enjoyed the three years that I spent on a CCG so much, because I knew that it was local and that every month I was going to be visiting a GP surgery. I knew all those things, and I felt that that was an important contribution to healthcare in my area.
The amendment in the name of the noble Lord, Lord Crisp, is particularly important. If primary healthcare and these local services do not work, the rest of the NHS falls over.

Lord Kamall: My Lords, I am grateful to all noble Lords who have spoken on these amendments in this debate and in Committee, but I am also grateful for the discussions that we have had between the various stages and the conversations that noble Lords have continued to have with my officials—indeed, right up to the dinner break this evening. I shall speak to Amendments 34, 35 and 55 in my name, which I hope will go far in addressing many of the concerns raised in the debate.
We have heard the calls for greater clarity about what will be expected of ICBs in their forward planning. We also understand the importance of ICBs being transparent in discharging their functions to allow for public scrutiny and accountability. We have therefore brought forward these amendments to further clarify what ICBs must include in their forward plans and annual reports. These amendments provide that the forward plan must describe what services the ICB proposes to make arrangements for in the exercise of its functions. It must also explain how the ICB proposes to discharge each of its duties under new Sections 14Z34 to 14Z44. These duties include improving the quality of services, reducing inequalities, promoting the involvement of patients and carers in decisions about treatment and promoting the integration of health and social care services.
Amendment 55 requires an ICB’s annual report to explain how it has discharged each of its duties under new Sections 14Z34 to 14Z44. This would additionally include new Section 14Z47A, which is the new duty we discussed earlier requiring the ICB to keep under review the skills, knowledge and experience that it needs to discharge its functions and, when there are gaps, to consider what steps it can take to address or mitigate them. I hope that noble Lords will agree that these amendments represent a significant step forward in making sure ICBs are held accountable by ensuring that they are transparent in how they intend to discharge their numerous duties and functions.
I turn to the amendments proposed by noble Lords, and I shall address each of them as briefly as I can. On Amendment 19, I assure my noble friend Lord Farmer that the Bill already includes the power for ICBs to commission services or facilities for the prevention of illness under new Section 3A in Clause 16. The provisions in Clause 16 also require ICBs to act consistently with the Secretary of State’s duty for the promotion of a comprehensive health service, including in the prevention of illness. Further, new Section 14Z34 places a duty on ICBs to improve the quality of services including preventive services, and new Sections 14Z36 and 14Z38 place duties on ICBs to ensure that patients and carers are fully involved in these decisions, including about prevention.
I now turn briefly to Amendment 62, spoken to so ably by my noble friend Lord McColl and the noble Baroness, Lady Hollins. I also pay tribute to the noble Baroness, Lady Greengross, who in my brief time in this House thus far has really educated me about dementia and the fact that, as we are living longer physically, this will become more of an issue.
The department is currently developing a new national dementia strategy for England, which will be published later this year. This will include objectives focused on restoring the dementia diagnosis rates and improving the diagnostic experience for people living with dementia, as well as increasing the number and diversity of people participating in dementia research. I take on board the concern of the noble Baroness, Lady Walmsley, about getting the many volunteers for clinical trials at the right time.
There is already work under way to help restore dementia diagnosis rates back to the target of 66.7% following the pandemic, supported by an additional £17 million to address dementia waiting lists and increase the number of diagnoses. Increasing participation in all types of research is a top priority and is in fact part of my portfolio. The UK has invested in a range of digital platforms, including Join Dementia Research, and we are now working to increase the scale of and interoperability between systems, improve diverse recruitment and reduce the burden and costs of clinical research delivery.
On Amendments 22 and 24, I reassure noble Lords that the Bill already contains requirements on NHS commissioning bodies to tackle health inequalities. Commissioners are also required to promote the right of patients to make choices with respect to services or treatment. This includes allowing patients to choose  to be treated outside their ICB area. To support this, we expect ICBs to actively co-operate with each other. Furthermore, we have amended the duty on ICBs to have regard to the need to reduce inequalities between patients, proposing by government amendment to extend this to “persons”, in respect of accessing services. This means we are capturing everyone, not just people accessing services. This duty would encompass the need to reduce inequalities with respect to geography as well.
I now turn to Amendment 30. I thank the noble Baroness, Lady Finlay. First, I should thank her for the daffodil I am wearing to celebrate St David’s Day. She assures me that it is not a listening device to eavesdrop on my conversations with officials. If she had eavesdropped, she probably would have been embarrassed by the amount of praise heaped on her. We acknowledge her desire to see strong provision of community rehabilitation and it is important that this is pushed up the agenda.
Under the existing Bill provisions, every ICB will be required to provide and improve rehabilitation services as part of its duty to provide a comprehensive health service. As an added layer of scrutiny, ICBs must publish an annual review detailing how they have discharged this function. Also, NHS England is currently working on a national intermediate care framework, digital and virtual pathways and models of care, improved data recording and reports, and interventions using a wide range of community assets and levers.
I now turn to Amendments 33 and 37 to 54. I thank the noble Lord, Lord Crisp, for his engagement on this issue—indeed, including right up to the dinner break this evening. We would like to put on record our gratitude to the noble Lord and the Royal College of General Practitioners for pushing us on this and reminding us that, as we move to ICBs, we should make sure that primary care is not the poor relation. In moving to ICBs from CCGs, where GPs and primary medical services have played a huge role, we have to ensure that these are not dominated by a few large trusts.
We understand and continue to recognise the importance of primary care. Indeed, primary care is taking on more of the functions of what would traditionally be considered secondary care, especially with some of the primary care services and community centres appearing in our local communities. Only this week, we have seen stories and press reports of pharmacists calling for more of the functions of GPs to be delegated to them. They have helpfully suggested that they could save the NHS money and also provide better primary care services by taking on some of those functions. There is clearly a demand out there and that has to be encouraged.
Before I turn to this, I note that we hold primary care in equal esteem to any other sector—acute, community or mental health. Right from the outset, we have said that primary care must not be lost and must be at the heart of the ICB. As the Integrated Care Systems: Design Framework said:
“Through a combination of their membership, and the ways in which members engage partners, the board and its committees should ensure they take into account the perspectives and expertise of all relevant partners”,
including primary care.
I know the noble Lord is especially concerned about why primary care is not explicitly referenced in new Clause 14Z50(1). I hope I can offer him some explanation. First, we are conscious that there are 43,000 primary care providers, and it is impractical to require each to be a partner in developing the ICB forward plan. Secondly, new Clause 14Z50 ties NHS providers to the plan, and a failure to play their part could trigger NHS England’s intervention. It will also guide the financial requirements imposed under Clause 24. In contrast, primary care providers, as private contractors, are bound to the plan in a different way, primarily through contracts. Thirdly, new Clauses 14Z50 and 14Z54, on the joint capital resource plan, are intimately connected and primary care capital is provided through other routes.
However, ensuring that the primary care voice is sufficiently involved in joint forward planning in integrated care boards is our common ambition. The law requires the involvement of a primary care representative drawn from primary medical services on ICBs, just as it does for acute providers. ICBs will have to consider how they can best access skills and knowledge across primary care.
In addition, there is a duty in new Clause 14Z52 to consult
“any other persons they consider it appropriate to consult”
about forward plans. We expect that, in publishing its plan, an ICB should set out how it has met this duty and consulted primary care and other partners. I am able to inform the House that NHS England has confirmed that its guidance will be explicit in its expectation that primary care will be a crucial partner in that process. We are happy to engage with the noble Lord further as that guidance develops to ensure that we stick to that commitment to make sure that primary care is at the heart of this.
More broadly, ICBs have the discretion to appoint additional members to the ICB or exercise functions through committees. Commissioning at a local level requires the expertise of primary care, and we expect it to play a significant role as many decisions will be taken at that level under the principle of subsidiarity. Further guidance will be published on the development of place- level arrangements, including the role of primary care.
I also note the Fuller review. NHS England chief executive Amanda Pritchard has announced that Dr Claire Fuller, senior responsible officer of the Surrey Heartlands Integrated Care System, will lead a review on how primary care networks can be supported in integrated systems. NHS England has announced that the review will set out how ICSs and primary care networks should go about improving out-of-hospital care. The findings of the review will then be applied to ICBs, subject to the passage of this Bill. We hope this work will help all ICBs to make progress on developing general practice in this area.
I hope I have been able to assure noble Lords that we hold primary care in great esteem, and have given the noble Lord some reassurance that primary care will be involved in every level of the ICB, its functions and planning.
I now turn to Amendment 177 from my noble friend Lady Hodgson. I thank her for continuing to remind us of its importance and speaking movingly about her  own experience. I remind noble Lords that all practices are already required to assign all their registered patients—including those aged 65 and over—a named, accountable GP. The GP must lead in ensuring that any GP services that they are contracted to provide, and that are necessary to meet the patient’s needs, are co-ordinated and delivered to that patient. Practices must take reasonable steps to accommodate the requests of patients to be assigned a particular GP and to see them for an appointment.
However, it is vital that practices retain clinical discretion to provide appointments, as is necessary and appropriate to meet the reasonable needs of patients—something that this amendment would remove. Through primary care networks and initiatives such as enhanced health in care homes and anticipatory care, we are supporting GP practices to improve continuity of care on the ground, including for older patients. We are committed to growing the general practice workforce and increasing access to appointments, in line with our manifesto commitments.
Let me finally very briefly touch on the point made by the noble Baroness, Lady Whitaker, about non-NHS services. We very much see them as part of the wider integrated care partnerships, in terms of making sure we deliver joined-up health and care.
This has been a wide-ranging debate and hope I have been able to provide some reassurances regarding noble Lords’ concerns.
I have just realised I did not directly answer the question from the noble Baroness, Lady Walmsley, about the experience in London and patients being sent elsewhere. I hope the noble Baroness will allow me to investigate further and write to her. On the other issues I hope I have been able to provide some reassurance regarding noble Lords’ concerns. I hope that noble Lords will feel able not to press their amendments when they are reached.

Lord Farmer: My Lords, I thank the Minister for his fairly comprehensive reply. I also thank many noble Lords for their contributions. I think the Minister’s description of the debate being wide-ranging was correct. It was noticeable also that there was a degree of sadness and regret that it was the end of the day and that this important subject could not have a longer period for debate. The whole area of prevention and primary care, and of named GPs, which my noble friend Lady Hodgson was talking about, is an area of early activity in the health of people which needs to be more debated. This debate has shown that the Bill has not given it the proper emphasis that one would want; the equality with the acute care that we have heard about.
It is late in the day, and I certainly do not want to detain the House, but I thank all noble Lords for their contributions. I hope that the Ministers can take this away and that if to a certain extent they are behind the curve on this front bit of health need, they will muse on it and improve the Bill, as the Minister said he intends to do. I thank noble Lords again and beg leave to withdraw my amendment.
Amendment 19 withdrawn.

Amendments 20 and 21

Lord Kamall: Moved by Lord Kamall
20: Clause 20, page 16, line 33, leave out “patients” and insert “persons”Member’s explanatory statementAn integrated care board has a duty to have regard to the need to reduce inequalities in access to health services for patients. The amendment extends it to cover people before they are patients.
21: Clause 20, page 16, line 36, at end insert “(including the outcomes described in section 14Z34(3))”Member’s explanatory statementThis amendment makes it explicit that the duty for an integrated care board to have regard to the need to reduce inequalities in outcomes for patients covers outcomes such as the quality of experience undergone by patients.
Amendments 20 and 21 agreed.
Amendment 22 not moved.

Amendment 23

Lord Kamall: Moved by Lord Kamall
23: Clause 20, page 17, line 16, at end insert “facilitate or otherwise”Member’s explanatory statementThis amendment provides that an integrated care board’s duty to promote research etc includes doing so by facilitating research.
Amendment 23 agreed.
Amendment 24 not moved.

Amendments 25 and 26

Lord Kamall: Moved by Lord Kamall
25: Clause 20, page 18, line 27, leave out “The reference in subsection (1)” and insert “In subsection (1)—(a) the reference”Member’s explanatory statementThis amendment is consequential on another amendment which provides that references in new section 14Z43 of the NHS Act 2006 to effects of a decision in relation to certain matters include its effects in relation to inequalities with respect to those matters.
26: Clause 20, page 18, line 30, at end insert—“(b) the reference to effects of a decision in relation to the health and well-being of the people of England includes a reference to its effects in relation to inequalities between the people of England with respect to their health and well-being;(c) the reference to effects of a decision in relation to the quality of services provided to individuals includes a reference to its effects in relation to inequalities between individuals with respect to the benefits that they can obtain from those services.”Member’s explanatory statementThis amendment provides that references in new section 14Z43 of the NHS Act 2006 to effects of a decision in relation to certain matters include its effects in relation to inequalities with respect to those matters.
Amendments 25 and 26 agreed.
Amendment 27 not moved.

Amendment 28

Lord Kamall: Moved by Lord Kamall
28: Clause 20, page 18, line 38, at end insert—“14Z43A Duties as to climate change etc(1) Each integrated care board must, in the exercise of its functions, have regard to the need to—(a) contribute towards compliance with—(i) section 1 of the Climate Change Act 2008 (UK net zero emissions target), and(ii) section 5 of the Environment Act 2021 (environmental targets), and(b) adapt to any current or predicted impacts of climate change identified in the most recent report under section 56 of the Climate Change Act 2008.(2) In discharging the duty under this section, integrated care boards must have regard to guidance published by NHS England under section 13ND.”Member’s explanatory statementThis amendment would require integrated care boards, in exercising their functions, to have regard to certain matters relating to the environment, including climate change.
Amendment 28 agreed.
Amendments 29 and 30 not moved.

Amendment 31

Lord Kamall: Moved by Lord Kamall
31: Clause 20, page 20, line 18, at end insert—“14Z47A Duty to keep experience of members under review etcAn integrated care board must—(a) keep under review the skills, knowledge and experience that it considers necessary for members of the board to possess (when taken together) in order for the board effectively to carry out its functions, and(b) if it considers that the board as constituted lacks the necessary skills, knowledge and experience, take such steps as it considers necessary to address or mitigate that shortcoming.”Member’s explanatory statementThis amendment requires an integrated care board to keep under review the skills, knowledge and experience that it is necessary to have on the board and take steps to address or mitigate shortcomings.
Amendment 31 agreed.
Amendments 32 and 33 not moved.

Amendments 34 and 35

Lord Kamall: Moved by Lord Kamall
34: Clause 20, page 21, line 12, at end insert—“(za) describe the health services for which the integrated care board proposes to make arrangements in the exercise of its functions by virtue of this Act;”Member’s explanatory statementThis amendment requires the joint forward plan for an integrated care board and its partners to describe the health services that the board proposes to commission over the next five years.
35: Clause 20, page 21, leave out lines 15 to 20 and insert—“(i) sections 14Z34 to 14Z44 (general duties of integrated care boards), and (ii) ”Member’s explanatory statementThis amendment requires the joint forward plan for an integrated care board and its partners, in particular, to explain how the board proposes to discharge its duties under sections 14Z34 to 14Z44 (rather than just some of those sections).
Amendments 34 and 35 agreed.
Consideration on Report adjourned.

Police, Crime, Sentencing and Courts Bill
 - Returned from the Commons

The Bill was returned from the Commons with amendments.
House adjourned at 10.49 pm.